Provider Demographics
NPI:1427155241
Name:HOMNICK, KENT JACK (MD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:JACK
Last Name:HOMNICK
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 1:42 UNITY PL
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-6188
Mailing Address - Country:US
Mailing Address - Phone:843-446-0937
Mailing Address - Fax:
Practice Address - Street 1:42 UNITY PL
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-6188
Practice Address - Country:US
Practice Address - Phone:843-446-0937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD32690207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN323292100Medicaid
MN323292100Medicaid