Provider Demographics
NPI:1265474324
Name:SHEA, KEVIN W (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:SHEA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:920 DOUG WHITE DR STE 250
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4181
Mailing Address - Country:US
Mailing Address - Phone:843-236-1950
Mailing Address - Fax:843-236-1952
Practice Address - Street 1:920 DOUG WHITE DR STE 250
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4181
Practice Address - Country:US
Practice Address - Phone:843-236-1950
Practice Address - Fax:843-236-1952
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC18455207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790646CMedicaid
SC184552Medicaid
SC440001329OtherRAILROAD MEDICARE