Provider Demographics
NPI:1710963269
Name:KENDALL, BRIAN W (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
Last Name:KENDALL
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:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4497
Mailing Address - Fax:803-536-0998
Practice Address - Street 1:3000 SAINT MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1442
Practice Address - Country:US
Practice Address - Phone:803-395-2200
Practice Address - Fax:803-536-0998
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI23476207R00000X
SC23476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC00000060163129OtherUNISON
SCT77191Medicaid
SC7854405OtherAETNA
SC20039168OtherFIRST CHOICE
SC4209804OtherCIGNA
SCH684587399Medicare ID - Type Unspecified
SCT77191Medicaid
SCP00108025Medicare PIN