Provider Demographics
NPI:1023009701
Name:BAXLEY, GEORGE TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:TIMOTHY
Last Name:BAXLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2089
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-2089
Mailing Address - Country:US
Mailing Address - Phone:864-855-5104
Mailing Address - Fax:864-855-5880
Practice Address - Street 1:220 KEOWEE TRL
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1448
Practice Address - Country:US
Practice Address - Phone:864-653-4071
Practice Address - Fax:864-653-4074
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC195882084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC195880Medicaid
SC195880Medicaid
SCH316849363Medicare PIN
SCH316845844Medicare PIN
SCP00167172Medicare ID - Type UnspecifiedRAILROAD MEDICARE