Provider Demographics
NPI:1265654511
Name:BEAUFORT ENT & ALLERGY LLC
Entity Type:Organization
Organization Name:BEAUFORT ENT & ALLERGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-525-6622
Mailing Address - Street 1:1231 RIBAUT RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6147
Mailing Address - Country:US
Mailing Address - Phone:843-525-6622
Mailing Address - Fax:
Practice Address - Street 1:1231 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6147
Practice Address - Country:US
Practice Address - Phone:843-525-6622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC003200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7215359OtherAETNA GROUP PIN
SC7326369OtherAETNA DON R CHRISTIAN PIN
SCGP3955Medicaid
SC228621Medicaid
SC4625215OtherAETNA KENNETH A BROWN PIN
SC1518130095OtherTRACY BRANDE M.S. NPI
SCTL5955Medicaid
SC1467455949OtherDON CHRISTIAN NPI
SC1699778076OtherKENNETH BROWNS NPI
SCCM4419Medicare PIN
SC1518130095OtherTRACY BRANDE M.S. NPI
SC7215359OtherAETNA GROUP PIN
SC228621Medicaid