MEDICARE: MR. BRIAN M HEASTER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	18825	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225010572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN M HEASTER MD

Provider Business Mailing Address
First Line	:	3400 WEST AVE
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6901
Country	:	US
Telephone Number	:	803-254-3676
Fax Number	:	803-254-3678

Provider Business Practice Location Address
First Line	:	201 CASHUA ST
Second Line	:
City	:	DARLINGTON
State	:	SC
Zip	:	29532-3301
Country	:	US
Telephone Number	:	843-393-7452
Fax Number	:	843-393-6310

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2005
Last Update Date	:	11/26/2007

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