Provider Demographics
NPI:1700880119
Name:WURTZ, KENNETH S (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:S
Last Name:WURTZ
Suffix:
Gender:M
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:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4561
Mailing Address - Fax:803-395-2237
Practice Address - Street 1:1161 COOK RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8204
Practice Address - Country:US
Practice Address - Phone:803-395-4600
Practice Address - Fax:803-395-4620
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2015-11-25
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
SC20014174400000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG25850Medicaid
SCD31458Medicare UPIN