Provider Demographics
NPI:1376685453
Name:BURNETT, BRYAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:A
Last Name:BURNETT
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 1:86 WREN ST
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-1529
Mailing Address - Country:US
Mailing Address - Phone:803-259-5762
Mailing Address - Fax:803-259-3250
Practice Address - Street 1:10706 MARLBORO AVE
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812-6376
Practice Address - Country:US
Practice Address - Phone:803-259-7337
Practice Address - Fax:803-259-9505
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21040208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT51958Medicaid
SC21040OtherMEDICAL LICENSE
SCL00061Medicaid
423836Medicare Oscar/Certification
SC570858468OtherCOMMERCIAL
SCRHC004Medicaid