Provider Demographics
NPI:1639120439
Name:WELBORN, MICHAEL KEASLER (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEASLER
Last Name:WELBORN
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 1315
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-1315
Mailing Address - Country:US
Mailing Address - Phone:864-635-0376
Mailing Address - Fax:864-442-6848
Practice Address - Street 1:115 BRUSHY CREEK RD
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-1120
Practice Address - Country:US
Practice Address - Phone:864-635-0376
Practice Address - Fax:864-442-6848
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5415207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC582296052-055OtherBLUE CROSS
SC054158Medicaid
SCB917546202Medicare PIN
SC582296052-055OtherBLUE CROSS
SCB917549367Medicare PIN