Healthcare Provider Details

I. General information

NPI: 1205863107
Provider Name (Legal Business Name): KEITH H WATERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 FAIRVIEW POINTE DRIVE
SIMPSONVILLE SC
29681
US

IV. Provider business mailing address

PO BOX 887
SIMPSONVILLE SC
29681
US

V. Phone/Fax

Practice location:
  • Phone: 864-967-4982
  • Fax: 864-967-8465
Mailing address:
  • Phone: 864-967-4982
  • Fax: 864-967-8465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9105
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: