Provider Demographics
NPI:1750333183
Name:VAUGHN, KENNETH WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:VAUGHN
Suffix:
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:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:101 EAST WOOD ST
Practice Address - Street 2:EMERGENCY CENTER
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6000
Practice Address - Fax:864-560-4413
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16851207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4214665OtherAETNA
SCP00760368OtherRAIL ROAD MEDICARE
SC20057606OtherSELECT HEALTH
NC690555TMedicaid
SCTL8042Medicaid
SC194177OtherMEDCAST
SCF48162Medicare PIN
SCP00388730Medicare PIN
NC690555TMedicaid
SC194177OtherMEDCAST
SCF481628510Medicare PIN