Basic Information
| Provider Information | |||||||||
| NPI: | 1518934587 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRYAN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | STONE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 MEDICAL PARK RD | ||||||||
| Address2: | SUITE 502 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035401000 | ||||||||
| FaxNumber: | 8035401079 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEDICAL PARK RD | ||||||||
| Address2: | SUITE 502 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035401000 | ||||||||
| FaxNumber: | 8035401079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 04/24/2008 | ||||||||
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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 | 207R00000X | 7126 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 7126 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 071264 | 05 | SC | MEDICAID |