Provider Demographics
NPI:1467833558
Name:KINKEAD, JODI
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:KINKEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEVEN
Other - Middle Name:K
Other - Last Name:WHITE
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1275 21ST AVE N
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-7514
Mailing Address - Country:US
Mailing Address - Phone:843-448-9977
Mailing Address - Fax:
Practice Address - Street 1:1275 21ST AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-7514
Practice Address - Country:US
Practice Address - Phone:843-448-9977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD10836174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1003096058Medicare UPIN