MEDICARE: BRETT WILLIAM ELDER

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1922626720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRETT WILLIAM ELDER

Provider Business Mailing Address
First Line	:	1051 SOUTHERN DR UNIT 3707
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-5622
Country	:	US
Telephone Number	:	503-508-2699
Fax Number	:

Provider Business Practice Location Address
First Line	:	1051 SOUTHERN DR UNIT 3707
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-5622
Country	:	US
Telephone Number	:	503-508-2699
Fax Number	:

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

Provider Enumeration Date	:	07/08/2020
Last Update Date	:	07/08/2020

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