Healthcare Provider Details

I. General information

NPI: 1912639683
Provider Name (Legal Business Name): CARSON BREWER MEDLIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARSON MACKENZIE IDA BREWER

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 CLEMSON BLVD STE 100
SENECA SC
29678-4545
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-482-6000
  • Fax: 864-482-7000
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4497
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: