Provider Demographics
NPI:1063473320
Name:CRUTCHER, KENNETH L (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:CRUTCHER
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 1:4303 LIVE OAK DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-9138
Mailing Address - Country:US
Mailing Address - Phone:843-663-8000
Mailing Address - Fax:
Practice Address - Street 1:4303 LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-9138
Practice Address - Country:US
Practice Address - Phone:843-663-8000
Practice Address - Fax:843-280-2455
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29550207Q00000X
SCMMD33307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8926422Medicaid
NC26422OtherBCBS
205685NMedicare PIN
NCC83411Medicare UPIN
P00301454Medicare PIN