Provider Demographics
NPI:1669489100
Name:THOMPSON, KENNETH ARTHUR (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ARTHUR
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-5139
Mailing Address - Fax:
Practice Address - Street 1:5010 CAROLINA FOREST BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-3579
Practice Address - Country:US
Practice Address - Phone:843-903-1010
Practice Address - Fax:843-903-1015
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1032207V00000X
NC2020-02536207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC000000204502OtherUNISON
SC408253OtherWELLCARE
SCGP4505Medicaid
SCP00689014OtherRR MEDICARE
SC0165925OtherGHI
SC010321Medicaid
SC5502655OtherAETNA
NC5905507Medicaid
SC010321Medicaid
SCG548975345Medicare PIN
SC408253OtherWELLCARE
SC7844Medicare PIN
SC5502655OtherAETNA