Provider Demographics
NPI:1013083690
Name:PEGRAM, DAVID W (PT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:W
Last Name:PEGRAM
Suffix:
Gender:M
Credentials:PT
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 3408
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-4015
Mailing Address - Country:US
Mailing Address - Phone:803-732-5887
Mailing Address - Fax:803-732-5997
Practice Address - Street 1:1075 BOILING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-2248
Practice Address - Country:US
Practice Address - Phone:864-580-2001
Practice Address - Fax:864-580-2003
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4544225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00372305OtherRAILROAD MEDICARE PIN
SCQ17259Medicare UPIN