Provider Demographics
NPI:1689692253
Name:BANNISTER, CARROLL BROOKS (MD)
Entity Type:Individual
Prefix:MR
First Name:CARROLL
Middle Name:BROOKS
Last Name:BANNISTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:701 MEDICAL PARK DR
Mailing Address - Street 2:STE 300
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-4777
Mailing Address - Country:US
Mailing Address - Phone:843-878-1101
Mailing Address - Fax:843-656-1212
Practice Address - Street 1:701 MEDICAL PARK DR
Practice Address - Street 2:SUITE 101
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4777
Practice Address - Country:US
Practice Address - Phone:843-339-4295
Practice Address - Fax:843-339-4609
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC7718208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC077188Medicaid
SC077188Medicaid