Provider Demographics
NPI:1740251503
Name:KISH, LAURENCE MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:MICHAEL
Last Name:KISH
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2202 CAROLINA PL
Practice Address - Street 2:STE 100
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-8807
Practice Address - Country:US
Practice Address - Phone:980-487-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600313207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC110228246OtherRAILROAD MEDICARE
NC19981OtherPARTNERS MEDICARE CHOICE
NC1740251503Medicaid
NC296858OtherMAMSI
NCB1161OtherMEDCOST
NC0400264OtherUNITED HEALTHCARE
NC1056POtherBCBS
SCN00313Medicaid
NC891056PMedicaid
NC2237170JMedicare PIN
NC19981OtherPARTNERS MEDICARE CHOICE
NC296858OtherMAMSI
NC1056POtherBCBS