Provider Demographics
NPI:1760479620
Name:CAROLINA FAMILY PRACTICE P A
Entity type:Organization
Organization Name:CAROLINA FAMILY PRACTICE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-383-0770
Mailing Address - Street 1:208 SWIFT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-4383
Mailing Address - Country:US
Mailing Address - Phone:843-383-0770
Mailing Address - Fax:843-383-5856
Practice Address - Street 1:208 SWIFT CREEK RD
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4383
Practice Address - Country:US
Practice Address - Phone:843-383-0770
Practice Address - Fax:843-383-5856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2918Medicaid
SCB92146Medicare UPIN