Provider Demographics
NPI:1821060336
Name:MOON, BRYAN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:SCOTT
Last Name:MOON
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 1:7 INDEPENDENCE PT
Mailing Address - Street 2:STE 140
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4566
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6195
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE C100
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-4260
Practice Address - Fax:864-676-0898
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23261207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT73603Medicaid
SC200044388OtherRR MEDICARE
SC576007863201OtherBCBS OF SC
SCT73603Medicaid
SC200044388OtherRR MEDICARE