Provider Demographics
NPI:1164506002
Name:KANEB, GRETCHEN
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:KANEB
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 1:41 PARK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4270
Mailing Address - Country:US
Mailing Address - Phone:864-299-1600
Mailing Address - Fax:864-422-2930
Practice Address - Street 1:41 PARK CREEK DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4270
Practice Address - Country:US
Practice Address - Phone:864-299-1600
Practice Address - Fax:864-422-2930
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229990207Q00000X
SC30352207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine