Provider Demographics
NPI:1326305210
Name:CAROLINA PEDIATRIC
Entity Type:Organization
Organization Name:CAROLINA PEDIATRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OP DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALETHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-364-1363
Mailing Address - Street 1:105 SCHOOL HOUSE ST
Mailing Address - Street 2:3
Mailing Address - City:RIDGEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29472
Mailing Address - Country:US
Mailing Address - Phone:843-364-1363
Mailing Address - Fax:
Practice Address - Street 1:105 SCHOOL ST
Practice Address - Street 2:3
Practice Address - City:RIDGEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29472-8040
Practice Address - Country:US
Practice Address - Phone:843-364-1363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG58526Medicaid