Provider Demographics
NPI:1124092630
Name:GARNER, FRED T (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:T
Last Name:GARNER
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 1:2295 HENRY TECKLENBURG DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-7801
Mailing Address - Country:US
Mailing Address - Phone:843-766-7103
Mailing Address - Fax:
Practice Address - Street 1:200 ARBOR LAKE DR STE 120
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4516
Practice Address - Country:US
Practice Address - Phone:843-766-7103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16045207Y00000X, 207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC570667594OtherTAX ID
SC204836403OtherTAX ID
SC160453Medicaid
SCF335521863Medicare ID - Type Unspecified
F33552Medicare UPIN