Provider Demographics
NPI:1477588655
Name:HELLER, KENNETH BRYAN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:BRYAN
Last Name:HELLER
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:PO BOX 846
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:SC
Mailing Address - Zip Code:29627-0846
Mailing Address - Country:US
Mailing Address - Phone:864-940-9701
Mailing Address - Fax:864-338-8760
Practice Address - Street 1:113 WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:SC
Practice Address - Zip Code:29627-9687
Practice Address - Country:US
Practice Address - Phone:864-940-9701
Practice Address - Fax:864-338-8760
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC09331208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC093311Medicaid
SC7117Medicare ID - Type Unspecified