Healthcare Provider Details

I. General information

NPI: 1275582397
Provider Name (Legal Business Name): EDWARD H HAUSLADEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 MEMORIAL DRIVE EXT SUITE C
GREER SC
29651-1155
US

IV. Provider business mailing address

1 INDEPENDENCE PT SUITE 212
GREENVILLE SC
29615-4545
US

V. Phone/Fax

Practice location:
  • Phone: 864-879-3883
  • Fax: 864-848-3492
Mailing address:
  • Phone: 864-797-6044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number15352
License Number StateSC

VII. Legacy identifiers

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

# 1
Identifier153522
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: