Basic Information
| Provider Information | |||||||||
| NPI: | 1811082928 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALMETTO HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EASLEY GENERAL SURGEONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 403 HILLCREST DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296401207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648551644 | ||||||||
| FaxNumber: | 8648556101 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 HILLCREST DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296401207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648551644 | ||||||||
| FaxNumber: | 8648556101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/09/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | PATTERSON | ||||||||
| AuthorizedOfficialFirstName: | SHIRLEY | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8648551644 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PALMETTO HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 572296052070 | 01 | SC | BLUE CROSS BLUE SHIELD | OTHER | PC6855 | 05 | SC | MEDICAID |