Basic Information
| Provider Information | |||||||||
| NPI: | 1891759510 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | KAM | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 SAM RITTENBERG BLVD STE 6 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294075031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439735393 | ||||||||
| FaxNumber: | 8339941098 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 SAM RITTENBERG BLVD STE 6 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294075031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439735393 | ||||||||
| FaxNumber: | 8339941098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21455 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | L32196 | 05 | SC | MEDICAID |