MEDICARE: BRUCE BRYON LATHAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	14072	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00802354	OTHER	SC	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194778589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE BRYON LATHAM MD

Provider Business Mailing Address
First Line	:	1 INDEPENDENCE PT STE 212
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-4536
Country	:	US
Telephone Number	:	864-797-6306
Fax Number	:

Provider Business Practice Location Address
First Line	:	877 W FARIS RD
Second Line	:	SUITE D
City	:	GREENVILLE
State	:	SC
Zip	:	29605-4254
Country	:	US
Telephone Number	:	864-455-9031
Fax Number	:	864-455-9014

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	07/21/2022

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