Basic Information
| Provider Information | |||||||||
| NPI: | 1841233848 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUDERER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976044 | ||||||||
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| Practice Location | |||||||||
| Address1: | 890 W FARIS RD | ||||||||
| Address2: | SUITE 440 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296054247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644555125 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 12/11/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 17609 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 57-6007863046 | 01 | SC | BCBS OF SC | OTHER | 1265047 | 01 | SC | CIGNA | OTHER | 176099 | 05 | SC | MEDICAID | 4007279 | 01 | SC | AETNA | OTHER |