Provider Demographics
NPI:1922092345
Name:ELLENBERG, BRYAN K (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:K
Last Name:ELLENBERG
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 1:1228 HWY 72 WEST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-1816
Mailing Address - Country:US
Mailing Address - Phone:864-943-0549
Mailing Address - Fax:864-227-2067
Practice Address - Street 1:1228 HIGHWAY 72 W
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-1816
Practice Address - Country:US
Practice Address - Phone:864-943-0549
Practice Address - Fax:864-227-2067
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCL19479Medicaid
SCF85489Medicare UPIN
SCF854895497Medicare PIN
SC080088078OtherRR MEDICARE