Provider Demographics
NPI:1083878813
Name:EDMISON, LACIE E (MD)
Entity Type:Individual
Prefix:DR
First Name:LACIE
Middle Name:E
Last Name:EDMISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LACIE
Other - Middle Name:E
Other - Last Name:BRENNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3980 HIGHWAY 9 E STE 320
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-8165
Mailing Address - Country:US
Mailing Address - Phone:843-366-3715
Mailing Address - Fax:843-366-3716
Practice Address - Street 1:3980 HIGHWAY 9 E STE 320
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566
Practice Address - Country:US
Practice Address - Phone:843-366-3715
Practice Address - Fax:843-366-3716
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01397207RG0100X
SC81622207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCF354AMedicare PIN