Basic Information
| Provider Information | |||||||||
| NPI: | 1982642880 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GARY J BARRETT MD PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CORPORATION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 156 | ||||||||
| Address2: | |||||||||
| City: | LORIS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437568090 | ||||||||
| FaxNumber: | 8437566122 | ||||||||
| Practice Location | |||||||||
| Address1: | 3109 CASEY ST | ||||||||
| Address2: | |||||||||
| City: | LORIS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437568090 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARRETT | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8437568090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 11051 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 890136N | 05 | NC | MEDICAID | GP0648 | 05 | SC | MEDICAID |