Provider Demographics
NPI:1255449203
Name:EGAN, BRENT MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:MICHAEL
Last Name:EGAN
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:STE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6306
Mailing Address - Fax:
Practice Address - Street 1:877 W FARIS RD
Practice Address - Street 2:STE. B
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4289
Practice Address - Country:US
Practice Address - Phone:864-455-6900
Practice Address - Fax:864-255-5619
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16346207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC163469Medicaid
SC163469Medicaid
SCA78541Medicare ID - Type Unspecified