Provider Demographics
NPI:1285809970
Name:GETTYS, EDNA KATHERINE GANTT
Entity type:Individual
Prefix:
First Name:EDNA KATHERINE
Middle Name:GANTT
Last Name:GETTYS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:727 SE MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3247
Practice Address - Country:US
Practice Address - Phone:864-522-1170
Practice Address - Fax:864-522-1175
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38843207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5918508Medicaid
SCNC1476Medicaid
SCSC71157951Medicare PIN
NCNC2089AMedicare PIN