=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255438610
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENNA B. DELAINE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1136 KINCAIDE BRIDGE RD STE A
-----------------------------------------------------
City | WINNSBORO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-635-1052
-----------------------------------------------------
Fax | 803-635-2297
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 WILD CHERRY RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29223-6730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-865-6678
-----------------------------------------------------
Fax | 803-798-7943
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 15886
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------