Provider Demographics
NPI:1699778076
Name:BROWN, KENNETH A (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:BROWN
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 1:2295 HENRY TECKLENBERG DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-7801
Mailing Address - Country:US
Mailing Address - Phone:843-766-7103
Mailing Address - Fax:
Practice Address - Street 1:1231 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6147
Practice Address - Country:US
Practice Address - Phone:843-525-6622
Practice Address - Fax:843-522-8243
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13736207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1265654511OtherGROUP BFTENT NPI
SC7215359OtherAETNA GROUP PIN
SC4625215OtherAETNA KENNETH A BROWN PIN
SCGP3955Medicaid
SCTL5955Medicaid
SCP00135885OtherRR MEDICARE PIN#
SCTL5955Medicaid
SC7987Medicare PIN
SCP00135885OtherRR MEDICARE PIN#
SCDB9047Medicare PIN