Provider Demographics
NPI:1598729386
Name:MENON, PREETH A (MD)
Entity Type:Individual
Prefix:
First Name:PREETH
Middle Name:A
Last Name:MENON
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 1:10105 FALLON FARM RD APT 302
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-7527
Mailing Address - Country:US
Mailing Address - Phone:704-578-8872
Mailing Address - Fax:
Practice Address - Street 1:CHARLESTON PAIN &REHABILITATION CENTER
Practice Address - Street 2:1124 SAM RITTENBERG BLVD STE 1
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-3362
Practice Address - Country:US
Practice Address - Phone:843-556-3462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22762207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC227622Medicaid
SC227622Medicaid