Provider Demographics
NPI:1619958485
Name:PARKE, C.W. KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:C.W.
Middle Name:KELLY
Last Name:PARKE
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 1:129 FLEETWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-2019
Mailing Address - Country:US
Mailing Address - Phone:864-855-4255
Mailing Address - Fax:864-855-4439
Practice Address - Street 1:129 FLEETWOOD DR
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-2019
Practice Address - Country:US
Practice Address - Phone:864-855-4255
Practice Address - Fax:864-855-4439
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28367174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC283678Medicaid
SCD86187Medicare UPIN
SC6992Medicare PIN