Provider Demographics
NPI:1255331054
Name:IWEGBUE, KWAME N (MD)
Entity Type:Individual
Prefix:DR
First Name:KWAME
Middle Name:N
Last Name:IWEGBUE
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:316 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1113
Practice Address - Country:US
Practice Address - Phone:843-724-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24486207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20 24486OtherSTATE REGISTRATION
SC244863Medicaid
SCECFMGOther05978218
SCP00469860OtherRAILROAD MEDICARE
SCP00727200OtherRAILROAD MEDICARE ID-RSFPN
SCECFMGOther05978218
SCP00469860OtherRAILROAD MEDICARE
SCAA02287891Medicare ID - Type UnspecifiedSECONDAY MEDICARE ID
SCH98718Medicare UPIN