Provider Demographics
NPI:1245244342
Name:FAIREY, JOHN O (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:O
Last Name:FAIREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1301 TAYLOR ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2942
Mailing Address - Country:US
Mailing Address - Phone:803-254-4591
Mailing Address - Fax:803-931-8000
Practice Address - Street 1:1301 TAYLOR ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2942
Practice Address - Country:US
Practice Address - Phone:803-254-4591
Practice Address - Fax:803-931-8000
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-12-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC11357208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC113576Medicaid
SC113576Medicaid