Provider Demographics
NPI:1245552843
Name:REARDEN INTERNAL MEDICINE & GERIATRICS LLC
Entity type:Organization
Organization Name:REARDEN INTERNAL MEDICINE & GERIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:LASHUN
Authorized Official - Last Name:REARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-277-2771
Mailing Address - Street 1:P O BOX 2191
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-3933
Mailing Address - Country:US
Mailing Address - Phone:843-277-2771
Mailing Address - Fax:843-277-2778
Practice Address - Street 1:1205 WISTERIA RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5226
Practice Address - Country:US
Practice Address - Phone:843-277-2771
Practice Address - Fax:843-277-2778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-23
Last Update Date:2015-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42D2093779OtherCLIA WAIVER
SC302586Medicaid
SC42D2052192OtherCLAI WAIVER