Provider Demographics
NPI:1972693257
Name:DEGENHART, VINCENT J (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:J
Last Name:DEGENHART
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 2344
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-2344
Mailing Address - Country:US
Mailing Address - Phone:803-254-2394
Mailing Address - Fax:803-254-7125
Practice Address - Street 1:1315 ROBERTS STREET
Practice Address - Street 2:KERSHAW HEALTH
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020
Practice Address - Country:US
Practice Address - Phone:803-713-2619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8917207LC0200X, 207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4129441OtherAETNA
SC050028863OtherRR MEDICARE
SC089175OtherSELECT HEALTH
SC77789OtherMEDCOST
SC089175Medicaid
SC2000078OtherCCP