Healthcare Provider Details

I. General information

NPI: 1659440907
Provider Name (Legal Business Name): KENNETH SCOTT EASTERS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH STREET AF-1020
AUGUSTA GA
30912
US

IV. Provider business mailing address

1120 15TH STREET AF-1020
AUGUSTA GA
30912
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-4467
  • Fax: 706-721-9081
Mailing address:
  • Phone: 706-721-4467
  • Fax: 706-721-9081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number10780
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10785
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: