=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902867724
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY J BRUNDAGE PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 04/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 608 E COLUMBIA AVE
-----------------------------------------------------
City | BATESBURG-LEESVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29070-7318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-359-2323
-----------------------------------------------------
Fax | 803-359-2331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 GATEWAY CORNERS PARK SUITE 102
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29203-8906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-359-2323
-----------------------------------------------------
Fax | 803-359-2331
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2581
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------