Basic Information
| Provider Information | |||||||||
| NPI: | 1457739377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AINSWORTH | ||||||||
| FirstName: | KALAH | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SINGLETON RIDGE RD | ||||||||
| Address2: | ATTENTION PATIENT ACCOUNTING | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432346946 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8004 MYRTLE TRACE DR | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432348939 | ||||||||
| FaxNumber: | 8432348959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2015 | ||||||||
| LastUpdateDate: | 04/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 83785 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 837857 | 05 | SC | MEDICAID |