Provider Demographics
NPI:1316218670
Name:REMEDY INTERNAL MEDICINE AND WELLNESS CENTER P A
Entity Type:Organization
Organization Name:REMEDY INTERNAL MEDICINE AND WELLNESS CENTER P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:A
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-737-5206
Mailing Address - Street 1:109 WAPPOO CREEK DR
Mailing Address - Street 2:2A
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2135
Mailing Address - Country:US
Mailing Address - Phone:843-737-5206
Mailing Address - Fax:843-795-7171
Practice Address - Street 1:109 WAPPOO CREEK DR
Practice Address - Street 2:2A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2135
Practice Address - Country:US
Practice Address - Phone:843-737-5206
Practice Address - Fax:843-795-7171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2013-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24910207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5892Medicaid
SCGP5892Medicaid