Provider Demographics
NPI:1821097825
Name:KEOWEE RADIOLOGY P A
Entity Type:Organization
Organization Name:KEOWEE RADIOLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:C
Authorized Official - Last Name:POLEYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-885-7113
Mailing Address - Street 1:PO BOX 49009
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-0001
Mailing Address - Country:US
Mailing Address - Phone:864-223-3070
Mailing Address - Fax:
Practice Address - Street 1:298 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9443
Practice Address - Country:US
Practice Address - Phone:864-885-7113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CH9258OtherRAILROAD MEDICARE
SC3270Medicaid
SC7105Medicare PIN