Provider Demographics
NPI:1295752111
Name:SICK, BRANDON ROGER (MD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:ROGER
Last Name:SICK
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:P O BOX 602120
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:28260-2120
Mailing Address - Country:US
Mailing Address - Phone:803-329-5131
Mailing Address - Fax:803-366-6600
Practice Address - Street 1:2633 CELANESE RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1205
Practice Address - Country:US
Practice Address - Phone:803-329-5131
Practice Address - Fax:803-366-6600
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17450207Q00000X
NC2006-00021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT13660Medicaid
NC13955OtherBLUE CROSS BLUE SHIELD
P00243983OtherRAILROAD MEDICARE
NC13955OtherBLUE CROSS BLUE SHIELD
NC2075642Medicare PIN
SCT13660Medicaid