Provider Demographics
NPI:1689069833
Name:BLANK, BRIAN MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MATTHEW
Last Name:BLANK
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 1:1068 N CHURCH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-1769
Mailing Address - Country:US
Mailing Address - Phone:864-702-2365
Mailing Address - Fax:864-474-4109
Practice Address - Street 1:1068 N CHURCH ST STE 101
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-1769
Practice Address - Country:US
Practice Address - Phone:864-702-2365
Practice Address - Fax:864-474-4109
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-04
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD52429207Q00000X
SC52429207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty