Provider Demographics
NPI:1659329373
Name:GWYN, DARRYL ROYCE (MD)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:ROYCE
Last Name:GWYN
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:6TH FLOOR, SUPPORT TOWER
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5611
Practice Address - Country:US
Practice Address - Phone:864-455-7146
Practice Address - Fax:864-455-5380
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC177252080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC177258Medicaid
SCG138537951Medicare PIN
SCG138537951Medicare PIN
SC5538664OtherAETNA
SCG138533640Medicare PIN
SC576007863032OtherBCBS OF SC
SC6525048OtherCIGNA
SCG13853Medicare UPIN