Healthcare Provider Details

I. General information

NPI: 1023009701
Provider Name (Legal Business Name): GEORGE TIMOTHY BAXLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 KEOWEE TRL
CLEMSON SC
29631-1448
US

IV. Provider business mailing address

PO BOX 2089
EASLEY SC
29641-2089
US

V. Phone/Fax

Practice location:
  • Phone: 864-653-4071
  • Fax: 864-653-4074
Mailing address:
  • Phone: 864-855-5104
  • Fax: 864-855-5880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number19588
License Number StateSC

VII. Legacy identifiers

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

# 1
Identifier195880
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: