Basic Information
| Provider Information | |||||||||
| NPI: | 1356652036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAGLE | ||||||||
| FirstName: | BRYSTOL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENDERSON | ||||||||
| OtherFirstName: | BRYSTOL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 125 DOUGHTY ST | ||||||||
| Address2: | STE 420 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294035741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437233441 | ||||||||
| FaxNumber: | 8438054040 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 DOUGHTY ST STE 420 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294035741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437233441 | ||||||||
| FaxNumber: | 8438054040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2010 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 32779 | SC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.