Provider Demographics
NPI:1780669564
Name:HENRY, BRIAN N (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:N
Last Name:HENRY
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 638
Mailing Address - Street 2:
Mailing Address - City:DUE WEST
Mailing Address - State:SC
Mailing Address - Zip Code:29639-0638
Mailing Address - Country:US
Mailing Address - Phone:864-379-2345
Mailing Address - Fax:864-379-3228
Practice Address - Street 1:6 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:DUE WEST
Practice Address - State:SC
Practice Address - Zip Code:29639-9554
Practice Address - Country:US
Practice Address - Phone:864-379-2345
Practice Address - Fax:864-379-3228
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13965207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLL6786Medicaid
SCLL6786Medicaid
SCD056623974Medicare ID - Type Unspecified