Basic Information
| Provider Information | |||||||||
| NPI: | 1225010572 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEASTER | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032543676 | ||||||||
| FaxNumber: | 8032543678 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 CASHUA ST | ||||||||
| Address2: | |||||||||
| City: | DARLINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295323301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433937452 | ||||||||
| FaxNumber: | 8433936310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 11/26/2007 | ||||||||
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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 | 207Q00000X | 18825 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 188255 | 05 | SC | MEDICAID |