Provider Demographics
NPI:1417146127
Name:RUSSELL G. GADDY M.D.
Entity Type:Organization
Organization Name:RUSSELL G. GADDY M.D.
Other - Org Name:WINCHESTER FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:G
Authorized Official - Last Name:GADDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-458-9999
Mailing Address - Street 1:10 WINCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2627
Mailing Address - Country:US
Mailing Address - Phone:864-458-9999
Mailing Address - Fax:864-234-7652
Practice Address - Street 1:10 WINCHESTER CT
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2627
Practice Address - Country:US
Practice Address - Phone:864-458-9999
Practice Address - Fax:864-234-7652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC007870207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCM7824OtherMEDICARE RAILROAD
SC207QG0300XOtherTAXONOMY CODE
SC007870Medicaid
SCCM7824OtherMEDICARE RAILROAD