Basic Information
Provider Information | |||||||||
NPI: | 1427481274 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAPTIST EASLEY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HERITAGE PEDIATRICS & INTERNAL MEDICINE WREN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 INDEPENDENCE PT | ||||||||
Address2: | SUITE 212 | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296154545 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8647976044 | ||||||||
FaxNumber: | 8647976198 | ||||||||
Practice Location | |||||||||
Address1: | 1115 WREN SCHOOL RD | ||||||||
Address2: |   | ||||||||
City: | PIEDMONT | ||||||||
State: | SC | ||||||||
PostalCode: | 296738033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8648590740 | ||||||||
FaxNumber: | 8648599008 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2013 | ||||||||
LastUpdateDate: | 08/15/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POPE | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | LARRY | ||||||||
AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR/CFO | ||||||||
AuthorizedOfficialTelephone: | 8645527610 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | GP5967 | 05 | SC |   | MEDICAID |