=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649357781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRYAN AND SANG MEDICAL ASSOCIATES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10187 DUNBARTON BLVD
-----------------------------------------------------
City | BARNWELL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29812-1418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-259-5391
-----------------------------------------------------
Fax | 803-259-0472
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3800
-----------------------------------------------------
City | AIKEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29802-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-648-0874
-----------------------------------------------------
Fax | 803-648-5665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. GASNEL E BRYAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 803-648-0874
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 12145
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------