Basic Information
| Provider Information | |||||||||
| NPI: | 1528058641 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KERSHAW HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KERSHAWHEALTH PRIMARY CARE AT ELGIN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1315 ROBERTS ST | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290203737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034324311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 40 PINNACLE PARKWAY | ||||||||
| Address2: | BUILDING 100 SUITE 208 | ||||||||
| City: | ELGIN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290458999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034245165 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 06/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | WEEKS | ||||||||
| AuthorizedOfficialFirstName: | DONNIE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8037136227 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP2222 | 05 | SC | MEDICAID |