Basic Information
| Provider Information | |||||||||
| NPI: | 1841286192 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINGSTREE FAMILY MEDICINE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 512 NELSON BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KINGSTREE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295564027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433555459 | ||||||||
| FaxNumber: | 8433559704 | ||||||||
| Practice Location | |||||||||
| Address1: | 512 NELSON BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KINGSTREE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295564027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433555459 | ||||||||
| FaxNumber: | 8433559704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | KEELS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8433555459 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11529 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP0509 | 05 | SC | MEDICAID |