Provider Demographics
NPI:1063417228
Name:WARREN, GERALD C (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:C
Last Name:WARREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85A SPRINGVIEW LANE
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485
Mailing Address - Country:US
Mailing Address - Phone:843-851-0200
Mailing Address - Fax:843-851-9398
Practice Address - Street 1:85 SPRINGVIEW LN UNIT A
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8119
Practice Address - Country:US
Practice Address - Phone:843-851-0200
Practice Address - Fax:843-851-9398
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2011-06-06
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
SC15402174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC020021063OtherRAILROAD MEDICARE
SCTL3921Medicaid
SCGP0766Medicaid
SCE83196Medicare UPIN
SCE831964440Medicare ID - Type Unspecified