Provider Demographics
NPI:1164834487
Name:KERSHAWHEALTH
Entity Type:Organization
Organization Name:KERSHAWHEALTH
Other - Org Name:KERSHAWHEALTH PRIMARY CARE AT CAMDEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP-COO & CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-713-2496
Mailing Address - Street 1:1111 MILL ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-3763
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 MILL ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-3763
Practice Address - Country:US
Practice Address - Phone:803-432-4311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KERSHAWHEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL 0101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3410OtherMEDICARE PTAN #
SC400480Medicaid