Basic Information
| Provider Information | |||||||||
| NPI: | 1578767323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'KELLY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | GAYLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645222286 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 727 SE MAIN ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296813247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644546440 | ||||||||
| FaxNumber: | 8644546445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 29908 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RA0000X | 29908 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine | 208000000X | 29908 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 299082 | 05 | SC | MEDICAID |