Provider Demographics
NPI:1568412476
Name:PALMETTO HEALTH ALLIANCE EASLEY
Entity Type:Organization
Organization Name:PALMETTO HEALTH ALLIANCE EASLEY
Other - Org Name:POWDERSVILLE MEDICAL PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PATIENT FINANCIAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-855-5104
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:864-859-9362
Practice Address - Street 1:15 ROE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-7423
Practice Address - Country:US
Practice Address - Phone:864-295-2308
Practice Address - Fax:864-295-2635
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO HEALTH ALLIANCE EASLEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2174Medicaid
SCGP2174Medicaid
SC5740Medicare PIN