Provider Demographics
NPI:1629269311
Name:EDFORD-DAVIS, KIM BETH (DO)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:BETH
Last Name:EDFORD-DAVIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 HARDEN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-7107
Mailing Address - Country:US
Mailing Address - Phone:877-866-7123
Mailing Address - Fax:
Practice Address - Street 1:2601 LAUREL ST
Practice Address - Street 2:SUITE 230
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2033
Practice Address - Country:US
Practice Address - Phone:803-227-5320
Practice Address - Fax:803-227-5326
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1376207R00000X, 207Q00000X
PAOT011965207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC013766Medicaid
SC013766Medicaid