Provider Demographics
NPI:1558355958
Name:BAROODY, BRENT J (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:J
Last Name:BAROODY
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 1:1523 HERITAGE LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-3197
Mailing Address - Country:US
Mailing Address - Phone:843-673-9992
Mailing Address - Fax:843-673-9996
Practice Address - Street 1:1523 HERITAGE LN
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-3197
Practice Address - Country:US
Practice Address - Phone:843-673-9992
Practice Address - Fax:843-673-9996
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23624207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2348Medicaid
H82048Medicare UPIN
SCGP2348Medicaid