Provider Demographics
NPI:1508088097
Name:GU, KENI (MD)
Entity Type:Individual
Prefix:
First Name:KENI
Middle Name:
Last Name:GU
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 1:8 MEMORIAL MEDICAL CT STE 1
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4400
Mailing Address - Country:US
Mailing Address - Phone:864-295-3492
Mailing Address - Fax:864-295-4817
Practice Address - Street 1:8 MEMORIAL MEDICAL CT STE 1
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4400
Practice Address - Country:US
Practice Address - Phone:864-295-3492
Practice Address - Fax:864-295-4817
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062213207ZH0000X, 207ZP0102X
SC83671207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG62213Medicaid
GA334298477AMedicaid
GA202I224577Medicare PIN