Provider Demographics
NPI:1982642880
Name:GARY J BARRETT MD PA
Entity Type:Organization
Organization Name:GARY J BARRETT MD PA
Other - Org Name:CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-756-8090
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569
Mailing Address - Country:US
Mailing Address - Phone:843-756-8090
Mailing Address - Fax:843-756-6122
Practice Address - Street 1:3109 CASEY ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569
Practice Address - Country:US
Practice Address - Phone:843-756-8090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11051207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890136NMedicaid
SCGP0648Medicaid
SCGP0648Medicaid
SC4338Medicare ID - Type Unspecified