Provider Demographics
NPI:1801878186
Name:SANTIAGO, KENNETH A (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:SANTIAGO
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 70157
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-0021
Mailing Address - Country:US
Mailing Address - Phone:843-516-2024
Mailing Address - Fax:
Practice Address - Street 1:9021 BELLA VERDE CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-5110
Practice Address - Country:US
Practice Address - Phone:843-516-2024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212611207R00000X
SC34596207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2098075Medicaid
SCGP4505Medicaid
SC7844OtherMEDIARE GROUP PTAN
SC345969Medicaid
I24950Medicare UPIN