Provider Demographics
NPI:1689644015
Name:KATEMBA, ELISA ANN (MD)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:ANN
Last Name:KATEMBA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:2660 REIDVILLE RD UNIT 1
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-3512
Practice Address - Country:US
Practice Address - Phone:864-560-9696
Practice Address - Fax:864-560-9636
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20262174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC202621Medicaid
SCG902256067OtherMEDICARE UPIN