Provider Demographics
NPI:1780660456
Name:MINCEY, KENNETH H (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:H
Last Name:MINCEY
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 1:3600 SEA MOUNTAIN HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-8161
Mailing Address - Country:US
Mailing Address - Phone:843-399-9774
Mailing Address - Fax:843-399-8657
Practice Address - Street 1:3600 SEA MOUNTAIN HWY
Practice Address - Street 2:SUITE A
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-8161
Practice Address - Country:US
Practice Address - Phone:843-399-9774
Practice Address - Fax:843-399-8657
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11033208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC570923578OtherBLUE CROSS BLUE SHIELD
SCGP0444Medicaid
SCD18177Medicare UPIN
SC3844Medicare ID - Type Unspecified