Provider Demographics
NPI:1144598681
Name:UNIVERSAL CENTER FOR PEDIATRIC & ADOLESCENT MEDICINE,LLC
Entity Type:Organization
Organization Name:UNIVERSAL CENTER FOR PEDIATRIC & ADOLESCENT MEDICINE,LLC
Other - Org Name:UCPAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSANA
Authorized Official - Middle Name:LABORDE
Authorized Official - Last Name:MARKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-682-4300
Mailing Address - Street 1:PO BOX 23916
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29925-3916
Mailing Address - Country:US
Mailing Address - Phone:843-682-4300
Mailing Address - Fax:843-682-4301
Practice Address - Street 1:843 WILLIAM HILTON PKWY
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29928-3444
Practice Address - Country:US
Practice Address - Phone:843-682-4300
Practice Address - Fax:843-682-4301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31267208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty