Healthcare Provider Details

I. General information

NPI: 1831150226
Provider Name (Legal Business Name): ELAINE B BAXLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 HIGHWAY 1 S
LUGOFF SC
29078-9174
US

IV. Provider business mailing address

1606 LAKEVIEW AVE
CAMDEN SC
29020-2929
US

V. Phone/Fax

Practice location:
  • Phone: 803-243-0988
  • Fax:
Mailing address:
  • Phone: 803-243-0988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number12579
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12579
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number12579
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: