Provider Demographics
NPI:1750354858
Name:FAILE, KENNETH M JR (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:FAILE
Suffix:JR
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-380-2000
Mailing Address - Fax:843-380-2014
Practice Address - Street 1:355 S. GEORGETOWN HWY
Practice Address - Street 2:
Practice Address - City:JOHNSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29555
Practice Address - Country:US
Practice Address - Phone:843-380-2000
Practice Address - Fax:843-380-2014
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT35012Medicaid
SCG79780Medicare UPIN
SCG797808552Medicare ID - Type Unspecified