Healthcare Provider Details

I. General information

NPI: 1306885462
Provider Name (Legal Business Name): PAUL EDMUNDS EASLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 09/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 HOSPITAL DR
TOCCOA GA
30577-6820
US

IV. Provider business mailing address

452 CROSS CREEK DR
TOCCOA GA
30577-2781
US

V. Phone/Fax

Practice location:
  • Phone: 706-282-4200
  • Fax: 706-886-8045
Mailing address:
  • Phone: 706-297-7749
  • Fax: 706-297-7749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberO24670
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierP00458724
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerMEDICARE RAILROAD
# 2
Identifier000263909C
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: