Healthcare Provider Details

I. General information

NPI: 1134567787
Provider Name (Legal Business Name): BRIAN CONRAD BRIMMAGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 LAKE BOONE TRL STE 405
RALEIGH NC
27607
US

IV. Provider business mailing address

4414 LAKE BOONE TRL STE 405
RALEIGH NC
27607-7520
US

V. Phone/Fax

Practice location:
  • Phone: 919-876-8225
  • Fax:
Mailing address:
  • Phone: 919-876-8225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number191913
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2017-00703
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: