Provider Demographics
NPI:1033278049
Name:REINWALD, KEITH C (PA-C)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:C
Last Name:REINWALD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2376 CYPRESS CIR STE 300
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8995
Mailing Address - Country:US
Mailing Address - Phone:843-347-7222
Mailing Address - Fax:843-347-3305
Practice Address - Street 1:2376 CYPRESS CIR STE 300
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8995
Practice Address - Country:US
Practice Address - Phone:843-347-7222
Practice Address - Fax:843-347-3305
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC582363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCS62112Medicare UPIN