Provider Demographics
NPI:1912288093
Name:KERSHAWHEALTH
Entity Type:Organization
Organization Name:KERSHAWHEALTH
Other - Org Name:KERSHAWHEALTH PRIMARY CARE AT LUGOFF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-713-6227
Mailing Address - Street 1:116 STANDARD WAREHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-9670
Mailing Address - Country:US
Mailing Address - Phone:803-438-6023
Mailing Address - Fax:803-438-3671
Practice Address - Street 1:116 STANDARD WAREHOUSE RD
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9670
Practice Address - Country:US
Practice Address - Phone:803-438-6023
Practice Address - Fax:803-438-3671
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KERSHAWHEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC400480Medicaid
SC3410Medicare PIN