Provider Demographics
NPI:1619174687
Name:C GREGORY KANG MD PA
Entity Type:Organization
Organization Name:C GREGORY KANG MD PA
Other - Org Name:PAIN, SPINE AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-215-8868
Mailing Address - Street 1:PO BOX 811
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-0811
Mailing Address - Country:US
Mailing Address - Phone:843-215-8868
Mailing Address - Fax:843-215-9555
Practice Address - Street 1:3029 NEWCASTLE LOOP
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588
Practice Address - Country:US
Practice Address - Phone:843-215-8868
Practice Address - Fax:843-215-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19925208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3898Medicaid
SCGP3898Medicaid
SC7514Medicare PIN