Provider Demographics
NPI:1174589204
Name:FISCHBACH, GARY T (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:T
Last Name:FISCHBACH
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 1:6124 WOODSIDE EXECUTIVE CT
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-3820
Mailing Address - Country:US
Mailing Address - Phone:803-226-0112
Mailing Address - Fax:803-226-0132
Practice Address - Street 1:6124 WOODSIDE EXECUTIVE CT
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-3820
Practice Address - Country:US
Practice Address - Phone:803-226-0112
Practice Address - Fax:803-226-0132
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0502521207Q00000X
SC10758207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC107583Medicaid
SC562134996OtherBCBS PROVIDER NUMBER
SCD17506Medicare UPIN
SC562134996OtherBCBS PROVIDER NUMBER