=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871911867
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRETT DANIEL VAN LEER-GREENBERG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2014
-----------------------------------------------------
Last Update Date | 03/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5500 FRONT ST # 260
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29486-7735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-376-0670
-----------------------------------------------------
Fax | 843-376-0669
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 530062
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30353-0062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-695-6071
-----------------------------------------------------
Fax | 843-568-5879
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 83995
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------