Provider Demographics
NPI:1225174667
Name:GAFFNEY UROLOGY PA
Entity Type:Organization
Organization Name:GAFFNEY UROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKATAIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-487-5124
Mailing Address - Street 1:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29342-0004
Mailing Address - Country:US
Mailing Address - Phone:864-487-5124
Mailing Address - Fax:864-487-5125
Practice Address - Street 1:140 4TH AVE
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29340-4726
Practice Address - Country:US
Practice Address - Phone:864-487-5124
Practice Address - Fax:864-487-5125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC09480174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3698Medicaid
SCGP3698Medicaid