Basic Information
| Provider Information | |||||||||
| NPI: | 1467411579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECKSTROM | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60314 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037651838 | ||||||||
| FaxNumber: | 8037651732 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 RICHLAND MEDICAL PARK | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292038000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034342797 | ||||||||
| FaxNumber: | 8034347038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 10/01/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 16621 | SC | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 16621 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 166215 | 05 | SC | MEDICAID |