Provider Demographics
NPI:1891779807
Name:BURNER, BRUCE ELLIS SR (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ELLIS
Last Name:BURNER
Suffix:SR
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 1440
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-1440
Mailing Address - Country:US
Mailing Address - Phone:843-433-8010
Mailing Address - Fax:843-433-8692
Practice Address - Street 1:618 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571-3034
Practice Address - Country:US
Practice Address - Phone:843-433-8010
Practice Address - Fax:843-433-8692
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12643207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC126438Medicaid
SCB92160Medicare UPIN
SCB921607153Medicare PIN
SC126438Medicaid