Provider Demographics
NPI:1588028880
Name:REIGHARD, SHANE GREGORY (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:GREGORY
Last Name:REIGHARD
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1330 BOILING SPRINGS RD STE 2500
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4214
Practice Address - Country:US
Practice Address - Phone:864-585-5433
Practice Address - Fax:864-591-4053
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC90834207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCR2029225OtherMEDICARE PIN
SCSCR2026084OtherMEDICARE PIN
SC908344Medicaid
SCSCR2023365OtherMEDICARE PIN