Healthcare Provider Details

I. General information

NPI: 1225199094
Provider Name (Legal Business Name): BRIAN J ROBERTS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 82ND PKWY
MYRTLE BEACH SC
29572-4607
US

IV. Provider business mailing address

823 82ND PKWY
MYRTLE BEACH SC
29572-4607
US

V. Phone/Fax

Practice location:
  • Phone: 843-449-1010
  • Fax: 843-497-6171
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number20257
License Number StateSC

VIII. Authorized Official

Name: CHRIS RICHARDSON
Title or Position: EXEC DIR
Credential:
Phone: 843-449-1010