Provider Demographics
NPI:1588908024
Name:FREDERICK T GARNER, MD, LLC
Entity type:Organization
Organization Name:FREDERICK T GARNER, MD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:TATUM
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-457-8120
Mailing Address - Street 1:200 ARBOR LAKE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-4516
Mailing Address - Country:US
Mailing Address - Phone:803-457-8120
Mailing Address - Fax:803-457-8129
Practice Address - Street 1:200 ARBOR LAKE DR STE 120
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4516
Practice Address - Country:US
Practice Address - Phone:803-457-8120
Practice Address - Fax:803-457-8129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6090Medicaid