Provider Demographics
NPI:1346636529
Name:BARNETT, ELYSE PAIGE (MD)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:PAIGE
Last Name:BARNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELYSE
Other - Middle Name:PAIGE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 MEDICAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4267
Practice Address - Country:US
Practice Address - Phone:864-522-5220
Practice Address - Fax:864-522-5296
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-00844208000000X
NC209560390200000X
SC87077208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC11494QMedicaid