Provider Demographics
NPI:1053376111
Name:ELLENBERGER, KURT RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:KURT
Middle Name:RICHARD
Last Name:ELLENBERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:955 RIBAUT RD
Mailing Address - Street 2:BMAC CREDENTIALING
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5441
Mailing Address - Country:US
Mailing Address - Phone:843-522-5674
Mailing Address - Fax:843-522-5678
Practice Address - Street 1:BEAUFORT MEMORIAL EXPRESS CARE & OCCUPATIONAL HEALTH
Practice Address - Street 2:974 RIBAUT RD
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902
Practice Address - Country:US
Practice Address - Phone:843-524-3344
Practice Address - Fax:844-295-9894
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC19453208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC194532Medicaid
SC19453OtherSC LICENSE BOARD