MEDICARE: DR. THEODORE EDWARD BRISSON 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	208800000X	Urology Physician	ME90953	FL
2	208800000X	Urology Physician	30581	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7026	OTHER	SC	MEDICARE GROUP

Other Identifiers

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

General Provider Information

NPI Number	:	1699759563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE EDWARD BRISSON M.D.

Provider Business Mailing Address
First Line	:	2890 TRICOM STREET
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-9171
Country	:	US
Telephone Number	:	843-797-6600
Fax Number	:	843-820-1440

Provider Business Practice Location Address
First Line	:	2890 TRICOM STREET
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-9171
Country	:	US
Telephone Number	:	843-797-6600
Fax Number	:	843-820-1440

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

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	04/17/2014

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