Basic Information
Provider Information | |||||||||
NPI: | 1811948896 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PALMETTO HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEDICAL CENTER OF EASLEY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2089 | ||||||||
Address2: |   | ||||||||
City: | EASLEY | ||||||||
State: | SC | ||||||||
PostalCode: | 296412089 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8648555104 | ||||||||
FaxNumber: | 8648599362 | ||||||||
Practice Location | |||||||||
Address1: | 104 FLEETWOOD DR | ||||||||
Address2: |   | ||||||||
City: | EASLEY | ||||||||
State: | SC | ||||||||
PostalCode: | 296402020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8648596331 | ||||||||
FaxNumber: | 8648551045 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2006 | ||||||||
LastUpdateDate: | 11/18/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DURHAM | ||||||||
AuthorizedOfficialFirstName: | KENDALL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PATIENT FINANCE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8648555104 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PALMETTO HEALTH | ||||||||
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 | PA2103 | 05 | SC |   | MEDICAID |