Healthcare Provider Details

I. General information

NPI: 1750471967
Provider Name (Legal Business Name): KEITH S. ROCKWILEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E JACKSON ST EMERGENCY DEPT.
DILLON SC
29536-2509
US

IV. Provider business mailing address

2849 DOGWOOD RD
TIMMONSVILLE SC
29161-8614
US

V. Phone/Fax

Practice location:
  • Phone: 843-774-4111
  • Fax:
Mailing address:
  • Phone: 843-346-1035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0002414
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: