Organization
KINGSTREE SURGICAL ASSOCIATES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BLAKE H MOORE MD, FACS (PRESIDENT)
(843) 355-5462
Entity
Organization
Contact information
Practice address
135 N ACADEMY ST, KINGSTREE, SC 29556-3421
(803) 731-8393
Mailing address
135 N ACADEMY ST, KINGSTREE, SC 29556-3421
(803) 731-8393
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
21490
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
21490
LICENSE
SC
05
—
T56301
—
SC
Enumeration date
10/15/2007
Last updated
03/07/2023
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