Provider Demographics
NPI:1467411579
Name:BECKSTROM, KATHRYN J (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:J
Last Name:BECKSTROM
Suffix:
Gender:F
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 60314
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0314
Mailing Address - Country:US
Mailing Address - Phone:803-765-1838
Mailing Address - Fax:803-765-1732
Practice Address - Street 1:5 RICHLAND MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8000
Practice Address - Country:US
Practice Address - Phone:803-434-2797
Practice Address - Fax:803-434-7038
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16621207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC166215Medicaid
F63270Medicare UPIN
SCF632703662Medicare PIN