Healthcare Provider Details

I. General information

NPI: 1710931290
Provider Name (Legal Business Name): EASLEY PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 NORTH A ST
EASLEY SC
29640
US

IV. Provider business mailing address

800 NORTH A ST
EASLEY SC
29640
US

V. Phone/Fax

Practice location:
  • Phone: 864-855-0001
  • Fax: 864-855-5030
Mailing address:
  • Phone: 864-855-0001
  • Fax: 864-855-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
IdentifierPA8900
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: MR. GARY MORGAN GOUDELOCK
Title or Position: PRESIDENT
Credential: MD
Phone: 864-855-0001