Provider Demographics
NPI:1457764169
Name:KERSHAWHEALTH
Entity Type:Organization
Organization Name:KERSHAWHEALTH
Other - Org Name:KERSHAWHEALTH SURGERY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP-COO & CFO
Authorized Official - Prefix:
Authorized Official - First Name:MIICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-713-2496
Mailing Address - Street 1:1102 ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-3734
Mailing Address - Country:US
Mailing Address - Phone:803-432-7682
Mailing Address - Fax:
Practice Address - Street 1:1102 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-3734
Practice Address - Country:US
Practice Address - Phone:803-432-7682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KERSHAWHEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL0101208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3410OtherMEDICARE PTAN
SC400480Medicaid