=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063079564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY SPEARMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2019
-----------------------------------------------------
Last Update Date | 10/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 VINECREST CT # 600
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29646-8031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-227-2900
-----------------------------------------------------
Fax | 864-227-6487
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 VINECREST CT # 600
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29646-8031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-227-2900
-----------------------------------------------------
Fax | 864-227-6487
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 82498
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------