Provider Demographics
NPI:1619965027
Name:RABON, BRIAN M (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:RABON
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 1:140 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9260
Mailing Address - Country:US
Mailing Address - Phone:843-234-5678
Mailing Address - Fax:843-234-4567
Practice Address - Street 1:140 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9260
Practice Address - Country:US
Practice Address - Phone:843-234-5678
Practice Address - Fax:843-234-4567
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22576208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4121Medicaid
SCGP4121Medicaid