Basic Information
Provider Information | |||||||||
NPI: | 1912102088 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASLEY ORTHOPAEDIC CLINIC, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | N/A | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 06/19/2007 | ||||||||
LastUpdateDate: | 09/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FINLEY | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 8648554431 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 8382 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 0529920001 | 01 | SC | MEDICARE DME | OTHER | PC2083 | 05 | SC |   | MEDICAID |