Provider Demographics
NPI:1639179591
Name:BRYANT, EARL W (MD)
Entity Type:Individual
Prefix:DR
First Name:EARL
Middle Name:W
Last Name:BRYANT
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 1:1346 HAILE ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020
Mailing Address - Country:US
Mailing Address - Phone:803-432-1931
Mailing Address - Fax:803-432-1176
Practice Address - Street 1:1346 HAILE ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020
Practice Address - Country:US
Practice Address - Phone:803-432-1931
Practice Address - Fax:803-432-1176
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9561208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC095612Medicaid
SCD99408Medicare UPIN
SCD994087203Medicare ID - Type Unspecified