Provider Demographics
NPI:1952365173
Name:EDENS, GREG W (MD)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:W
Last Name:EDENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ASHMORE CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:SC
Mailing Address - Zip Code:29657-9299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 BRUSHY CREEK RD
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-2200
Practice Address - Country:US
Practice Address - Phone:864-306-9661
Practice Address - Fax:864-306-8560
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC187540Medicaid
SC080173716OtherRAILROAD MEDICARE
SCG608496789Medicare PIN
SC080173716OtherRAILROAD MEDICARE