Basic Information
| Provider Information | |||||||||
| NPI: | 1679669162 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOUGHTON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SPRING FOREST RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276162880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198820706 | ||||||||
| FaxNumber: | 9198739821 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 E CHEVES ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295062617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437772000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 04/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 021424 | SC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | T54875 | 05 | SC | MEDICAID | 89066V5 | 05 | NC | MEDICAID | BH4710275 | 01 | SC | DEA | OTHER |