Provider Demographics
NPI:1558315267
Name:SHERARD, GORDON B III (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:B
Last Name:SHERARD
Suffix:III
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 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1686 SKYLYN DRIVE
Practice Address - Street 2:STE 101
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307
Practice Address - Country:US
Practice Address - Phone:864-585-3456
Practice Address - Fax:864-585-3209
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22965207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC229657Medicaid
SCP00691790OtherRR MEDICARE
H57421Medicare UPIN
SCH574216162Medicare PIN
SCP00691790OtherRR MEDICARE
SC5878670010Medicare NSC
SC229657Medicaid