Healthcare Provider Details

I. General information

NPI: 1578517470
Provider Name (Legal Business Name): CAROL A KETCHEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1686 SKYLYN DRIVE SUITE 101
SPARTANBURG SC
29307
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 864-585-3456
  • Fax: 864-585-3209
Mailing address:
  • Phone: 864-560-4304
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number14819
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: