Provider Demographics
NPI:1699228734
Name:BRYAN, CHACEY (MD)
Entity type:Individual
Prefix:DR
First Name:CHACEY
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 FRANKLIN SQUARE WAY STE A
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-3715
Mailing Address - Country:US
Mailing Address - Phone:864-442-4110
Mailing Address - Fax:864-442-4126
Practice Address - Street 1:3205 RANDALL PKWY STE 105
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2565
Practice Address - Country:US
Practice Address - Phone:910-742-9243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87072207Q00000X, 208D00000X
NY296938-1208D00000X
NC2024-01387208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC870720Medicaid