Healthcare Provider Details

I. General information

NPI: 1629053822
Provider Name (Legal Business Name): KEITH M HART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E GREENVILLE ST STE 3000
ANDERSON SC
29621
US

IV. Provider business mailing address

PO BOX 100174
COLUMBIA SC
29202-3174
US

V. Phone/Fax

Practice location:
  • Phone: 864-512-6760
  • Fax: 864-224-3773
Mailing address:
  • Phone: 864-512-6760
  • Fax: 864-224-3773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12019
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierGP5476
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 2
Identifier000400265C
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 3
Identifier120194
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: