Provider Demographics
NPI:1598777864
Name:MCKOY, BRODIE EDEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRODIE
Middle Name:EDEN
Last Name:MCKOY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:851 LEONARD FULGHUM DR 101
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3793
Mailing Address - Country:US
Mailing Address - Phone:843-971-9350
Mailing Address - Fax:843-971-9351
Practice Address - Street 1:851 LEONARD FULGHUM BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3787
Practice Address - Country:US
Practice Address - Phone:843-971-9750
Practice Address - Fax:843-971-9351
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20250207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20250OtherSTATE LICENSE
GA054413OtherSTATE LICENSE
SC202505Medicaid
SC202505Medicaid
GA054413OtherSTATE LICENSE
GA58-2555251Other(TIN) DOL OWCP/WC
BM5441249OtherDEA
GAI12591Medicare UPIN