Basic Information
| Provider Information | |||||||||
| NPI: | 1023009701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAXLEY | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | TIMOTHY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2089 | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296412089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648555104 | ||||||||
| FaxNumber: | 8648555880 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 KEOWEE TRL | ||||||||
| Address2: | |||||||||
| City: | CLEMSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296311448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8646534071 | ||||||||
| FaxNumber: | 8646534074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 07/29/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 19588 | SC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 195880 | 05 | SC | MEDICAID |