Healthcare Provider Details

I. General information

NPI: 1699228734
Provider Name (Legal Business Name): CHACEY BRYAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 RANDALL PKWY STE 105
WILMINGTON NC
28403-2565
US

IV. Provider business mailing address

105 FRANKLIN SQUARE WAY STE A
EASLEY SC
29642-3715
US

V. Phone/Fax

Practice location:
  • Phone: 910-742-9243
  • Fax:
Mailing address:
  • Phone: 864-442-4110
  • Fax: 864-442-4126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number87072
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number296938-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number87072
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2024-01387
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: