Provider Demographics
NPI:1295465763
Name:EMBER MODERN MEDICINE
Entity Type:Organization
Organization Name:EMBER MODERN MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-702-2365
Mailing Address - Street 1:1068 N CHURCH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-1769
Mailing Address - Country:US
Mailing Address - Phone:864-702-2365
Mailing Address - Fax:864-474-4109
Practice Address - Street 1:1068 N CHURCH ST STE 101
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-1769
Practice Address - Country:US
Practice Address - Phone:864-702-2365
Practice Address - Fax:864-474-4109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty