1912110586 NPI number — PALMETTO HEALTH ALLIANCE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912110586 NPI number — PALMETTO HEALTH ALLIANCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALMETTO HEALTH ALLIANCE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EASLEY FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912110586
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2089
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASLEY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29641-2089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-855-5104
Provider Business Mailing Address Fax Number:
864-859-9362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 JOHN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EASLEY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-859-2220
Provider Business Practice Location Address Fax Number:
864-859-5744
Provider Enumeration Date:
05/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DURHAM
Authorized Official First Name:
KENDALL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
FINANCIAL SERVICES REP-MANAGER
Authorized Official Telephone Number:
864-855-5104

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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