NPIMap

Individual provider Active NPI

Walter R Kirby, PA-C

  • Physician Assistant
  • Fairfax, SC
National Provider Identifier
1649414905
Registry record updated Jan 11, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
2214 Issued in SC
Practice address
333 Revolutionary TRL
Fairfax, SC 29827-7109
Phone
(803) 632-2533
Fax
(803) 632-2451
NPI assigned
Apr 29, 2009
Last updated
Jan 11, 2024By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 11, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 2214 SC Primary

Addresses

Primary practice location

333 Revolutionary TRL
Fairfax, SC 29827-7109

Mailing address

86 Wren St
Barnwell, SC 29812-1529
Phone (803) 259-5762

Other identifiers 2

IdentifierTypeStateIssuer
2119PAMedicaidSC
2214OtherSCMEDICAL LICENSE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20150625001032 SC Practitioner - Physician Assistant 8123339538 Reassigns benefits to 5 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Medical University of South Carolina College of Medicine, 2014
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Low Country Health Care System IncGroup PAC ID 4284530940, shared by 10 NPIs, 33 clinicians

Practice addresses (Care Compare)

333 Revoluntionary Trail
Fairfax, SC 29827-7109

333 Revolutionary TRL
Fairfax, SC 29827-7109
Phone (803) 632-2533

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
2214SCMDHealth Service Psychologist

Practice roles

OrganizationSpecialtyStatusNew patients
Low Country Health Care System, Inc CurrentSince Apr 15, 2020 Accepting new patients
Low Country Health Care System, Inc. CurrentSince Apr 15, 2015 Accepting new patients
Low Country Health Care System, Inc. CurrentSince Apr 15, 2015 Accepting new patients
Low Country Health Care System, Inc CurrentSince Nov 1, 2020 Accepting new patients
Low Country Health Care System, Inc CurrentSince Nov 1, 2020 Accepting new patients
Low Country Health Care System, Inc Current Accepting new patients
Low Country Health Care System, Inc Past Accepting new patients

Locations

185 McGee St
Bamberg, SC 29003
Phone (803) 245-4327

526 North St
Bamberg, SC 29003
Phone (803) 245-2433

10706 Marlboro Ave
Barnwell, SC 29812
Phone (803) 259-7337

124 Wren St
Barnwell, SC 29812
Phone (803) 254-3278

86 Wren St
Barnwell, SC 29812
Phone (803) 259-5762

130 Baker St N
Blackville, SC 29817
Phone (803) 284-1045

333 Revolutionary Trl
Fairfax, SC 29827
Phone (803) 632-2533

Organizations & group practices 8

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 2

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1240963200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1704931200000",
    "number": "1649414905",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "86 WREN ST",
            "city": "BARNWELL",
            "state": "SC",
            "postal_code": "298121529",
            "telephone_number": "803-259-5762"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "333 REVOLUTIONARY TRL",
            "city": "FAIRFAX",
            "state": "SC",
            "postal_code": "298277109",
            "telephone_number": "803-632-2533",
            "fax_number": "803-632-2451"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KIRBY",
        "first_name": "WALTER",
        "middle_name": "R",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2009-04-29",
        "last_updated": "2024-01-11",
        "certification_date": "2024-01-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "SC",
            "license": "2214",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2119PA",
            "state": "SC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL LICENSE",
            "identifier": "2214",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fairfax, SC

Sources for this page

Verify at the official NPI Registry.