Provider Demographics
NPI:1689878357
Name:KERSHAWHEALTH
Entity Type:Organization
Organization Name:KERSHAWHEALTH
Other - Org Name:DIABETES EDUCATIONAL PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-713-2065
Mailing Address - Street 1:1315 ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-3737
Mailing Address - Country:US
Mailing Address - Phone:803-432-4311
Mailing Address - Fax:
Practice Address - Street 1:1315 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-3737
Practice Address - Country:US
Practice Address - Phone:803-432-4311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCID#005277261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDPE066Medicaid
SC=========OtherUNITED HEALTHCARE ID#
SC=========OtherBLUE CHOICE
SC=========OtherBCBS OF S.C PROVIDER ID #
SCDPE066Medicaid
420048Medicare Oscar/Certification