Provider Demographics
NPI:1710989264
Name:WYCHE, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WYCHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2180
Mailing Address - Street 2:SUITE 2001
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-2180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2376 CYPRESS CIR
Practice Address - Street 2:SUITE 102
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8964
Practice Address - Country:US
Practice Address - Phone:843-347-8953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22925207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP01204809OtherRAILROAD MEDICARE
SC229256Medicaid
SC229256Medicaid