Healthcare Provider Details

I. General information

NPI: 1841236395
Provider Name (Legal Business Name): PRAMOD REDDY GANTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 N MAIN ST STE G
ANDERSON SC
29621
US

IV. Provider business mailing address

2508 N MAIN ST STE G
ANDERSON SC
29621-3266
US

V. Phone/Fax

Practice location:
  • Phone: 864-540-8430
  • Fax: 866-421-1896
Mailing address:
  • Phone: 864-540-8430
  • Fax: 866-421-1896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number19517
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number19517
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number35066
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: