1689692253 NPI number — MR. CARROLL BROOKS BANNISTER MD

Table of content: MR. CARROLL BROOKS BANNISTER MD (NPI 1689692253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689692253 NPI number — MR. CARROLL BROOKS BANNISTER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANNISTER
Provider First Name:
CARROLL
Provider Middle Name:
BROOKS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689692253
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 MEDICAL PARK DR
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
HARTSVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29550-4777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-878-1101
Provider Business Mailing Address Fax Number:
843-656-1212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
HARTSVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29550-4777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-339-4295
Provider Business Practice Location Address Fax Number:
843-339-4609
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  7718 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 077188 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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