Healthcare Provider Details

I. General information

NPI: 1538137724
Provider Name (Legal Business Name): BRIAN DAVID TALLERICO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

986 WELLNESS WAY STE 300
FORT MILL SC
29715-7353
US

IV. Provider business mailing address

17 LANSING ST
AUBURN NY
13021-1983
US

V. Phone/Fax

Practice location:
  • Phone: 803-930-9401
  • Fax: 803-462-4847
Mailing address:
  • Phone: 315-567-0455
  • Fax: 315-253-1795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036144262
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number7324A
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number295000
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number89674
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: