Healthcare Provider Details

I. General information

NPI: 1013597236
Provider Name (Legal Business Name): BREANNA MARIE KOETTER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-0100
US

IV. Provider business mailing address

498 ALBEMARLE RD UNIT 103
CHARLESTON SC
29407-7570
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMMD88280MD
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: