Basic Information
| Provider Information | |||||||||
| NPI: | 1053372805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANNON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 MEDICAL PARK RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292038003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032553417 | ||||||||
| FaxNumber: | 8032553451 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 MEDICAL PARK RD | ||||||||
| Address2: | SUITE 104B | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292038003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034344300 | ||||||||
| FaxNumber: | 8032554277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 4539 | SC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 045392 | 05 | SC | MEDICAID |