Provider Demographics
NPI:1487621959
Name:MCREDMOND, KEVIN P (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:MCREDMOND
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 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7313
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:7 MEDICAL PARK RD
Practice Address - Street 2:SUITE 203
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6873
Practice Address - Country:US
Practice Address - Phone:803-434-3533
Practice Address - Fax:803-434-3094
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC154412080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL4573Medicaid
SCB9060615769Medicare ID - Type Unspecified
SCTL4573Medicaid
SCB906065771Medicare PIN