Provider Demographics
NPI:1386692036
Name:WAGSTAFF, REBECCA LEIGH (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEIGH
Last Name:WAGSTAFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LEIGH
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203441207RH0002X, 208M00000X
SC25607207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC75729068OtherMEDICARE PIN
SC256074Medicaid
SC576007863071OtherBLUECHOICE HEALTHPLAN ID
SCP01577390OtherRAILROAD MEDICARE
SCSC75725019OtherMEDICARE PIN
MS03087834Medicaid
SC3283927OtherCIGNA ID
SC576007863095OtherBCBS OF SC ID
LA1811726Medicaid
SC7027607OtherAETNA ID
SCP00113665OtherRR MEDICARE
LA1811726Medicaid
SCP00113665OtherRR MEDICARE
SC7027607OtherAETNA ID
SC256074Medicaid