Provider Demographics
NPI:1932259538
Name:BURNS, BRUCE MALLORY (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:MALLORY
Last Name:BURNS
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 1:211 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29624-1620
Mailing Address - Country:US
Mailing Address - Phone:864-226-0511
Mailing Address - Fax:864-231-7018
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-226-0511
Practice Address - Fax:864-231-7018
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC139472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC57-0853635OtherCHAMPUS
GA00259223COtherMEDICAID
SC300020824OtherRAIL ROAD MEDICARE
SCTL4055Medicaid
SC57-0853635OtherBLUE CROSS
SCD056563030Medicare PIN
D05656Medicare UPIN
SC57-0853635OtherBLUE CROSS