Provider Demographics
NPI:1053426353
Name:F.M.A., P.A.
Entity type:Organization
Organization Name:F.M.A., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-654-7841
Mailing Address - Street 1:522 COLLEGE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-1443
Mailing Address - Country:US
Mailing Address - Phone:864-654-7841
Mailing Address - Fax:864-654-7641
Practice Address - Street 1:522 COLLEGE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1443
Practice Address - Country:US
Practice Address - Phone:864-654-7841
Practice Address - Fax:864-654-7641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC24081OtherDR. TOLBERT STATE LICENSE
SC9992OtherGENTRY STATE LICENSE
SCPC3475Medicaid
SCI36014Medicare UPIN
SC24081OtherDR. TOLBERT STATE LICENSE
SCPC3475Medicaid