1376500173 NPI number — KELLY LEE BROWN CRNA

Table of content: KELLY LEE BROWN CRNA (NPI 1376500173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376500173 NPI number — KELLY LEE BROWN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
KELLY
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

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:
1376500173
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1321 LADY ST
Provider Second Line Business Mailing Address:
FIRST FLOOR
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-296-2548
Provider Business Mailing Address Fax Number:
803-296-2525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 PAMPLICO HWY
Provider Second Line Business Practice Location Address:
CAROLINAS HOSPITAL SYSTEM
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29505-6047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-674-5000
Provider Business Practice Location Address Fax Number:
843-674-2519
Provider Enumeration Date:
04/27/2006

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: 367500000X , with the licence number:  659 , 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: AN0557 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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