Provider Demographics
NPI:1891779641
Name:DICKINSON, LEWIS GARRETT (MD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:GARRETT
Last Name:DICKINSON
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-366-3729
Mailing Address - Fax:843-777-7102
Practice Address - Street 1:200 S HERLONG AVE STE G
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1182
Practice Address - Country:US
Practice Address - Phone:803-909-6300
Practice Address - Fax:803-909-6310
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22540208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT67022Medicaid
H36160Medicare UPIN
H36160Medicare UPIN