Provider Demographics
NPI:1265481543
Name:WIDENHOUSE, BRIAN GLENN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:GLENN
Last Name:WIDENHOUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2683 LAKE PARK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9100
Mailing Address - Country:US
Mailing Address - Phone:843-518-5000
Mailing Address - Fax:843-614-8959
Practice Address - Street 1:2683 LAKE PARK DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9100
Practice Address - Country:US
Practice Address - Phone:843-518-5000
Practice Address - Fax:843-614-8959
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC200962086S0122X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC200963Medicaid
SCG68767Medicare UPIN
SCG687670281Medicare PIN