Basic Information
| Provider Information | |||||||||
| NPI: | 1891779641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKINSON | ||||||||
| FirstName: | LEWIS | ||||||||
| MiddleName: | GARRETT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433663729 | ||||||||
| FaxNumber: | 8437777102 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S HERLONG AVE STE G | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039096300 | ||||||||
| FaxNumber: | 8039096310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 12/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 22540 | SC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | T67022 | 05 | SC | MEDICAID |