Provider Demographics
NPI:1992705099
Name:KITCH, RUSSELL DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:DAVID
Last Name:KITCH
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 1:2850 TRICOM STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9192
Mailing Address - Country:US
Mailing Address - Phone:843-863-1188
Mailing Address - Fax:843-863-8286
Practice Address - Street 1:2850 TRICOM STREET
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9192
Practice Address - Country:US
Practice Address - Phone:843-863-1188
Practice Address - Fax:843-863-8286
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15299207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2380Medicaid
SC152943Medicaid
SC152943Medicaid
SCGP2380Medicaid