Provider Demographics
NPI:1891770319
Name:KISH, ROBERT NICHOLAS (DPM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:NICHOLAS
Last Name:KISH
Suffix:
Gender:M
Credentials:DPM
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 24293
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29224-4293
Mailing Address - Country:US
Mailing Address - Phone:803-466-0504
Mailing Address - Fax:
Practice Address - Street 1:411 LOCKMAN RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-8715
Practice Address - Country:US
Practice Address - Phone:803-466-0504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC144213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPD1448Medicaid
SCPD1448Medicaid
SCQ311270281Medicare ID - Type UnspecifiedPODIATRIST