Provider Demographics
NPI:1003924093
Name:WENZ, KENNETH JAAN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAAN
Last Name:WENZ
Suffix:
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 1:210 VILLAGE CENTER BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6707
Mailing Address - Country:US
Mailing Address - Phone:843-353-3460
Mailing Address - Fax:
Practice Address - Street 1:210 VILLAGE CENTER BLVD STE 150
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-6707
Practice Address - Country:US
Practice Address - Phone:843-353-3460
Practice Address - Fax:843-903-9032
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17498208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC201138864OtherMEDCOST GROUP NUMBER
SC201138864OtherTRICARE GROUP
SC6060061000OtherUS DEPT OF LABOR ACS
SC2020277OtherCAROLINA CARE PLAN
NC790629NMedicaid
NC89016NGMedicaid
SCGP3980Medicaid
SC201138864OtherBCBS OF SC
SC88677OtherMEDCOST
SCP00140610OtherRR MEDICARE
SCT14883Medicaid
SC201138864OtherGROUP NUMBER FOR CCP
SCDB9785OtherRR MEDICARE GROUP
SCP00140610OtherRR MEDICARE
SC201138864OtherMEDCOST GROUP NUMBER
SC88677OtherMEDCOST
SC88677OtherMEDCOST