Provider Demographics
NPI:1790736809
Name:WARREN, EDWARD III (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:WARREN
Suffix:III
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 1:595 W CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:VARNVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29944-4735
Mailing Address - Country:US
Mailing Address - Phone:803-943-7600
Mailing Address - Fax:803-943-7601
Practice Address - Street 1:595 W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:VARNVILLE
Practice Address - State:SC
Practice Address - Zip Code:29944-4735
Practice Address - Country:US
Practice Address - Phone:803-943-7600
Practice Address - Fax:803-943-7601
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC077132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC077133Medicaid
SCP00294591OtherRAILROAD MEDICARE ID
SCD470497089Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
SC077133Medicaid