Healthcare Provider Details

I. General information

NPI: 1649875816
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP SOUTH CAROLINA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DOCTORS DR
GREENVILLE SC
29605-4266
US

IV. Provider business mailing address

1 DOCTORS DR
GREENVILLE SC
29605-4266
US

V. Phone/Fax

Practice location:
  • Phone: 864-572-7001
  • Fax: 864-412-0436
Mailing address:
  • Phone: 864-572-7001
  • Fax: 864-412-0436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT OSBORNE BROWN
Title or Position: MD-GREENVILLE ENT & ALLERGY ASSOC.
Credential: MD
Phone: 833-450-0514