Provider Demographics
NPI:1093741266
Name:BEASLEY, VIRGINIA (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W A AVE
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-2051
Mailing Address - Country:US
Mailing Address - Phone:864-855-5104
Mailing Address - Fax:864-859-9362
Practice Address - Street 1:201 W A AVE
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-2051
Practice Address - Country:US
Practice Address - Phone:864-855-5104
Practice Address - Fax:864-859-9362
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC126054Medicaid
SCB922889371Medicare PIN
SC126054Medicaid
SCAA18006202Medicare PIN
SCB92288Medicare UPIN