Provider Demographics
NPI:1609018001
Name:HARTKE, AMANDA GALLOWAY (MD, PHD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GALLOWAY
Last Name:HARTKE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:HOPE
Other - Last Name:GALLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:20 MEDICAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4267
Practice Address - Country:US
Practice Address - Phone:864-220-7272
Practice Address - Fax:864-241-9211
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36647208000000X, 208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC366473Medicaid
SC366473Medicaid