Provider Demographics
NPI:1962691022
Name:KINGSTREE SURGICAL ASSOCIATES
Entity type:Organization
Organization Name:KINGSTREE SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:843-355-5462
Mailing Address - Street 1:135 N ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-3421
Mailing Address - Country:US
Mailing Address - Phone:803-731-8393
Mailing Address - Fax:
Practice Address - Street 1:135 N ACADEMY ST
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-3421
Practice Address - Country:US
Practice Address - Phone:803-731-8393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21490208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC21490OtherLICENSE
SCT56301Medicaid
SCT56301Medicaid
SCBM4461872OtherDEA
SCG02660Medicare UPIN