Provider Demographics
NPI:1245202217
Name:SOUTHSIDE PEDIATRICS OF AIKEN, LLC
Entity Type:Organization
Organization Name:SOUTHSIDE PEDIATRICS OF AIKEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:CLAUDE
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-642-9204
Mailing Address - Street 1:206 CENTRE SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-6319
Mailing Address - Country:US
Mailing Address - Phone:803-642-9204
Mailing Address - Fax:
Practice Address - Street 1:206 CENTRE SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-6319
Practice Address - Country:US
Practice Address - Phone:803-642-9204
Practice Address - Fax:803-648-3633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11083208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC5204Medicaid