Provider Demographics
NPI:1427138528
Name:MALCOLM, GREGORY R (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:R
Last Name:MALCOLM
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 3387
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21705-3387
Mailing Address - Country:US
Mailing Address - Phone:888-276-1910
Mailing Address - Fax:803-708-1370
Practice Address - Street 1:240 STONERIDGE DR
Practice Address - Street 2:SUITE 304
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-8013
Practice Address - Country:US
Practice Address - Phone:803-708-8126
Practice Address - Fax:803-708-1370
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12464207L00000X, 207LC0200X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2001038OtherCCP
SC124644OtherSELECT HEALTH
SC77844OtherMEDCOST
SC050028871OtherRR MEDICARE
SC4130018OtherAETNA
SC124644Medicaid
SC2001038OtherCCP
SC77844OtherMEDCOST