Provider Demographics
NPI:1730139429
Name:FRIDY, W WALLACE JR (MD)
Entity Type:Individual
Prefix:
First Name:W
Middle Name:WALLACE
Last Name:FRIDY
Suffix:JR
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 1:21 ABERDEEN DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-2955
Mailing Address - Country:US
Mailing Address - Phone:864-242-4122
Mailing Address - Fax:864-242-5867
Practice Address - Street 1:21 ABERDEEN DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-2955
Practice Address - Country:US
Practice Address - Phone:864-242-4122
Practice Address - Fax:864-242-5867
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD99220Medicare UPIN