Healthcare Provider Details

I. General information

NPI: 1518942044
Provider Name (Legal Business Name): W KENNETH EASLEY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S VENTURE DR
GREENVILLE SC
29615-3571
US

IV. Provider business mailing address

101 S VENTURE DR
GREENVILLE SC
29615-3571
US

V. Phone/Fax

Practice location:
  • Phone: 864-297-0087
  • Fax:
Mailing address:
  • Phone: 864-297-0087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number10526
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: