Basic Information
| Provider Information | |||||||||
| NPI: | 1093741266 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEASLEY | ||||||||
| FirstName: | VIRGINIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 W A AVE | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296402051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648555104 | ||||||||
| FaxNumber: | 8648599362 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 W A AVE | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296402051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648555104 | ||||||||
| FaxNumber: | 8648599362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 02/10/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 12605 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 126054 | 05 | SC | MEDICAID |