Provider Demographics
NPI:1841286192
Name:KINGSTREE FAMILY MEDICINE PA
Entity type:Organization
Organization Name:KINGSTREE FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:KEELS
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-355-5459
Mailing Address - Street 1:512 NELSON BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-4027
Mailing Address - Country:US
Mailing Address - Phone:843-355-5459
Mailing Address - Fax:843-355-9704
Practice Address - Street 1:512 NELSON BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-4027
Practice Address - Country:US
Practice Address - Phone:843-355-5459
Practice Address - Fax:843-355-9704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11529207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0509Medicaid
SC4114Medicare PIN
SCD17845Medicare UPIN