Provider Demographics
NPI:1861451650
Name:EWING, GARY BOGART (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:BOGART
Last Name:EWING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6808
Mailing Address - Country:US
Mailing Address - Phone:803-212-7130
Mailing Address - Fax:803-212-7160
Practice Address - Street 1:2 MEDICAL PARK RD
Practice Address - Street 2:SUITE 203
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6808
Practice Address - Country:US
Practice Address - Phone:803-212-7130
Practice Address - Fax:803-212-7160
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC179132083P0901X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC179130Medicaid
G10096Medicare UPIN
SCG100964950Medicare PIN