Healthcare Provider Details

I. General information

NPI: 1689642514
Provider Name (Legal Business Name): JAMES H BRUNSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 BOULEVARD ST
ORANGEBURG SC
29115-4359
US

IV. Provider business mailing address

PO BOX 1245
ORANGEBURG SC
29116-1245
US

V. Phone/Fax

Practice location:
  • Phone: 803-533-0042
  • Fax: 803-536-5220
Mailing address:
  • Phone: 803-395-4497
  • Fax: 803-536-0998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8154
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: