Provider Demographics
NPI:1396012126
Name:VALCOURT PEDIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:VALCOURT PEDIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINSTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MAREE
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-782-3636
Mailing Address - Street 1:124 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-5719
Mailing Address - Country:US
Mailing Address - Phone:843-782-3636
Mailing Address - Fax:843-782-3269
Practice Address - Street 1:124 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-5719
Practice Address - Country:US
Practice Address - Phone:843-782-3636
Practice Address - Fax:843-782-3269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29352208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG58526Medicaid