Provider Demographics
NPI:1588744957
Name:SMITH, BRENDAN E (MD)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:E
Last Name:SMITH
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 1:16 OKATIE CENTER BOULEVARD SOUTH SUITE 101
Mailing Address - Street 2:
Mailing Address - City:OKATIE
Mailing Address - State:SC
Mailing Address - Zip Code:29909-7533
Mailing Address - Country:US
Mailing Address - Phone:843-705-8940
Mailing Address - Fax:843-705-6816
Practice Address - Street 1:16 OKATIE CENTER BOULEVARD SOUTH SUITE 101
Practice Address - Street 2:
Practice Address - City:OKATIE
Practice Address - State:SC
Practice Address - Zip Code:29909-7533
Practice Address - Country:US
Practice Address - Phone:843-705-8940
Practice Address - Fax:843-705-6816
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22095174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT59479Medicaid
SCT59479Medicaid
SCF03008Medicare UPIN