Provider Demographics
NPI:1003878455
Name:KEITH, EDWARD C JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:KEITH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E HOSPITAL ST
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-3152
Mailing Address - Country:US
Mailing Address - Phone:803-435-2529
Mailing Address - Fax:803-435-4196
Practice Address - Street 1:15 E HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3152
Practice Address - Country:US
Practice Address - Phone:803-435-2529
Practice Address - Fax:803-435-4196
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13275207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC132751Medicaid
SCC67167Medicare UPIN
SC5865Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER