Provider Demographics
NPI:1306822879
Name:EWART, THOMAS W (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:EWART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 OFFICE PARK RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-5959
Mailing Address - Country:US
Mailing Address - Phone:803-699-5540
Mailing Address - Fax:803-699-5547
Practice Address - Street 1:105 OFFICE PARK RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-5959
Practice Address - Country:US
Practice Address - Phone:803-699-5540
Practice Address - Fax:803-699-5547
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9893174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC098931Medicaid
SCB925597807Medicare PIN
SCB92559Medicare UPIN