Provider Demographics
NPI:1710931290
Name:EASLEY PEDIATRICS PA
Entity Type:Organization
Organization Name:EASLEY PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MORGAN
Authorized Official - Last Name:GOUDELOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-855-0001
Mailing Address - Street 1:800 NORTH A ST
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640
Mailing Address - Country:US
Mailing Address - Phone:864-855-0001
Mailing Address - Fax:864-855-5030
Practice Address - Street 1:800 NORTH A ST
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640
Practice Address - Country:US
Practice Address - Phone:864-855-0001
Practice Address - Fax:864-855-5030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA8900Medicaid