Provider Demographics
NPI:1194870998
Name:FISCHBACH FAMILY MEDICINE & OPTHAMOLOGY
Entity type:Organization
Organization Name:FISCHBACH FAMILY MEDICINE & OPTHAMOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:FISCHBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-643-3400
Mailing Address - Street 1:3772 IVEY LANE
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-2156
Mailing Address - Country:US
Mailing Address - Phone:803-643-3400
Mailing Address - Fax:803-643-3440
Practice Address - Street 1:721 RICHLAND AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3831
Practice Address - Country:US
Practice Address - Phone:803-643-3400
Practice Address - Fax:803-643-3440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0502521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC107583Medicaid
SCGP2515OtherMEDICAID GROUP NUMBER
SCGP2515OtherMEDICAID GROUP NUMBER
SC107583Medicaid