Provider Demographics
NPI:1487792248
Name:INTERNAL MEDICINE OF WALTERBORO
Entity type:Organization
Organization Name:INTERNAL MEDICINE OF WALTERBORO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:KRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-542-9535
Mailing Address - Street 1:873 ROBERTSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488
Mailing Address - Country:US
Mailing Address - Phone:843-542-9535
Mailing Address - Fax:843-542-9675
Practice Address - Street 1:873 ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488
Practice Address - Country:US
Practice Address - Phone:843-542-9535
Practice Address - Fax:843-542-9675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18426207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC184268Medicaid
SCG649288697OtherMEDICARE ID
SCGP2942Medicaid
SCG649288697OtherMEDICARE ID
SCGP2942Medicaid