Provider Demographics
NPI:1316919194
Name:FOGARTY, CHARLES M (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:FOGARTY
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:PO BOX 4276
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29305
Mailing Address - Country:US
Mailing Address - Phone:864-582-6858
Mailing Address - Fax:864-585-0999
Practice Address - Street 1:2030 N CHURCH PLACE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303
Practice Address - Country:US
Practice Address - Phone:864-558-2685
Practice Address - Fax:864-585-0999
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8691207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC086917Medicaid
SC8688OtherMBPG'S
SC290011624OtherRAILROAD
SC086917Medicaid
SC290011624OtherRAILROAD
B91383Medicare UPIN