Provider Demographics
NPI:1093059214
Name:CLEMSON-SENECA PEDIATRICS
Entity Type:Organization
Organization Name:CLEMSON-SENECA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCCAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-885-7673
Mailing Address - Street 1:301 MEMORIAL DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29672-9445
Mailing Address - Country:US
Mailing Address - Phone:864-885-7989
Mailing Address - Fax:864-885-7867
Practice Address - Street 1:207 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-3245
Practice Address - Country:US
Practice Address - Phone:864-888-4222
Practice Address - Fax:864-888-0023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC423886OtherRHC