Provider Demographics
NPI:1437131877
Name:PHELAN, BRIAN K (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:PHELAN
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 1:820 ST. SEBASTIAN WAY
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901
Mailing Address - Country:US
Mailing Address - Phone:706-722-1249
Mailing Address - Fax:706-722-1947
Practice Address - Street 1:820 ST. SEBASTIAN WAY
Practice Address - Street 2:SUITE 2A
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901
Practice Address - Country:US
Practice Address - Phone:706-722-1249
Practice Address - Fax:706-722-1947
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027422174400000X, 207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000305214CMedicaid
GA06BDFDFMedicare ID - Type Unspecified
GAD30461Medicare UPIN