Basic Information
| Provider Information | |||||||||
| NPI: | 1568412476 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALMETTO HEALTH ALLIANCE EASLEY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | POWDERSVILLE MEDICAL PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2089 | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296412089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648555104 | ||||||||
| FaxNumber: | 8648599362 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 ROE RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296117423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642952308 | ||||||||
| FaxNumber: | 8642952635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DURHAM | ||||||||
| AuthorizedOfficialFirstName: | KENDALL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT FINANCIAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8648555104 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PALMETTO HEALTH ALLIANCE EASLEY | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP2174 | 05 | SC | MEDICAID |