MEDICARE: BRIAN GLENN WIDENHOUSE M.D.

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	2086S0122X	Plastic and Reconstructive Surgery Physician	20096	SC

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	:	1265481543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN GLENN WIDENHOUSE M.D.

Provider Business Mailing Address
First Line	:	2683 LAKE PARK DR
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-9100
Country	:	US
Telephone Number	:	843-518-5000
Fax Number	:	843-614-8959

Provider Business Practice Location Address
First Line	:	2683 LAKE PARK DR
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-9100
Country	:	US
Telephone Number	:	843-518-5000
Fax Number	:	843-614-8959

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

Provider Enumeration Date	:	05/06/2006
Last Update Date	:	04/03/2017

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