Basic Information
| Provider Information | |||||||||
| NPI: | 1356508659 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALMETTO HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EASLEY ORTHOPAEDIC CLINIC, PA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 704 N A ST | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296402142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648554431 | ||||||||
| FaxNumber: | 8643060012 | ||||||||
| Practice Location | |||||||||
| Address1: | 704 N A ST | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296402142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648554431 | ||||||||
| FaxNumber: | 8643060012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 09/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | PIPER | ||||||||
| AuthorizedOfficialFirstName: | JOYCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8648554431 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PALMETTO HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | PC2083 | 05 | SC | MEDICAID |