Provider Demographics
NPI:1548604275
Name:CHEDISTER, GABRIEL RYAN (MD)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:RYAN
Last Name:CHEDISTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:125 DOUGHTY ST STE 280
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5727
Practice Address - Country:US
Practice Address - Phone:843-958-1281
Practice Address - Fax:843-958-1278
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2022-08-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC35767208C00000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC357679Medicaid