Provider Demographics
NPI:1548219058
Name:ORBECK, KENNETH PETER (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PETER
Last Name:ORBECK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 21ST AVE N STE 105
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-7431
Mailing Address - Country:US
Mailing Address - Phone:843-839-0270
Mailing Address - Fax:843-839-0276
Practice Address - Street 1:1240 21ST AVE N
Practice Address - Street 2:SUITE 105
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-7401
Practice Address - Country:US
Practice Address - Phone:843-839-0270
Practice Address - Fax:843-839-0276
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0513207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT00149Medicaid
SCT00149Medicaid
SCE262550281Medicare ID - Type Unspecified