Provider Demographics
NPI:1750493250
Name:AMAECHI, PRINCE KESIDE (MD)
Entity Type:Individual
Prefix:DR
First Name:PRINCE
Middle Name:KESIDE
Last Name:AMAECHI
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 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:322 N PINE ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1631
Practice Address - Country:US
Practice Address - Phone:864-582-5099
Practice Address - Fax:864-327-1098
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32684207R00000X, 208M00000X, 207RN0300X
VA0101240360207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC326846Medicaid
SCP00899815OtherRAILROAD MEDICARE
NC5916344Medicaid
SCGP4718Medicaid
SCP01079099OtherRAILROAD MEDICARE
VAVAA101128Medicare PIN
SCAA55575019Medicare PIN