Healthcare Provider Details

I. General information

NPI: 1508836974
Provider Name (Legal Business Name): EASLEY M R I L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FLEETWOOD DR SUITE 100
EASLEY SC
29640-2022
US

IV. Provider business mailing address

PO BOX 3088
GREENVILLE SC
29602-3088
US

V. Phone/Fax

Practice location:
  • Phone: 864-552-7470
  • Fax: 864-552-7471
Mailing address:
  • Phone: 864-552-7470
  • Fax: 864-552-7471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
IdentifierSL0051
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 2
IdentifierCJ7945
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name: DR. CHARLES DAVID WILLIAMS III
Title or Position: PRESIDENT
Credential: M D
Phone: 864-295-4410