Healthcare Provider Details

I. General information

NPI: 1871957746
Provider Name (Legal Business Name): BRADLEY KETNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR BLDG A
GREENVILLE SC
29615-3593
US

IV. Provider business mailing address

200 PATEWOOD DR BLDG A
GREENVILLE SC
29615-3593
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-5115
  • Fax:
Mailing address:
  • Phone: 864-454-5115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101262858
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberLL92742
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: