Provider Demographics
NPI:1972561751
Name:BACHUS KEITH, BERYL LYNETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:BERYL
Middle Name:LYNETTE
Last Name:BACHUS KEITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 N IRBY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-2808
Mailing Address - Country:US
Mailing Address - Phone:843-667-9414
Mailing Address - Fax:847-667-1362
Practice Address - Street 1:11 W HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2912
Practice Address - Country:US
Practice Address - Phone:803-433-4124
Practice Address - Fax:803-433-4230
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16299208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCF96582Medicare ID - Type Unspecified