Provider Demographics
NPI:1891985982
Name:WOODLANDWAY FAMILY PRACTICE
Entity Type:Organization
Organization Name:WOODLANDWAY FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:H
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-972-5720
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:FAIR PLAY
Mailing Address - State:SC
Mailing Address - Zip Code:29643-0098
Mailing Address - Country:US
Mailing Address - Phone:864-972-5720
Mailing Address - Fax:
Practice Address - Street 1:111 WEST PINE GROVE RD
Practice Address - Street 2:
Practice Address - City:FAIRPLAY
Practice Address - State:SC
Practice Address - Zip Code:29643
Practice Address - Country:US
Practice Address - Phone:864-972-5720
Practice Address - Fax:864-972-5724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC235720Medicaid
SC7738Medicare PIN
SC235720Medicaid