Provider Demographics
NPI:1982699179
Name:FOOTHILLS INTERNAL MEDICINE
Entity Type:Organization
Organization Name:FOOTHILLS INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-855-1331
Mailing Address - Street 1:1648 GENTRY MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-8877
Mailing Address - Country:US
Mailing Address - Phone:864-855-1331
Mailing Address - Fax:864-855-1602
Practice Address - Street 1:1648 GENTRY MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-8877
Practice Address - Country:US
Practice Address - Phone:864-855-1331
Practice Address - Fax:864-855-1602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0069Medicaid
SCGP0069Medicaid