Provider Demographics
NPI:1366455206
Name:WARRICK, KENNETH RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RAY
Last Name:WARRICK
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 1:2237 HIGHWAY 9 E
Mailing Address - Street 2:
Mailing Address - City:LONGS
Mailing Address - State:SC
Mailing Address - Zip Code:29568-5701
Mailing Address - Country:US
Mailing Address - Phone:843-399-9965
Mailing Address - Fax:843-399-9974
Practice Address - Street 1:2237 HIGHWAY 9 E
Practice Address - Street 2:
Practice Address - City:LONGS
Practice Address - State:SC
Practice Address - Zip Code:29568-5701
Practice Address - Country:US
Practice Address - Phone:843-399-9965
Practice Address - Fax:843-399-9974
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40472207N00000X, 207NS0135X
SC7540207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCB91769Medicare UPIN
SCAA9029Medicare UPIN
TNB91769Medicare UPIN