Provider Demographics
NPI:1669443479
Name:LAWRENCE, KENNETH GRAHAM JR (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:GRAHAM
Last Name:LAWRENCE
Suffix:JR
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:406 MEMORIAL DRIVE EXT
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-1818
Practice Address - Country:US
Practice Address - Phone:864-877-9066
Practice Address - Fax:864-848-3291
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC26868OtherMEDCOST
SC4317938OtherAETNA
SC083983Medicaid
SC4317938OtherAETNA
SC083983Medicaid
SCB92254Medicare UPIN