Healthcare Provider Details

I. General information

NPI: 1881038065
Provider Name (Legal Business Name): KATIE WITTWER GAMBRELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GROVE RD
GREENVILLE SC
29605-4210
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-3287
  • Fax:
Mailing address:
  • Phone: 864-522-8617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.128873
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number51198
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: