Provider Demographics
NPI:1437168135
Name:SWEETGRASS PEDIATRICS
Entity Type:Organization
Organization Name:SWEETGRASS PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:HILTON
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-764-1722
Mailing Address - Street 1:2713 DANTZLER DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9005
Mailing Address - Country:US
Mailing Address - Phone:843-764-1722
Mailing Address - Fax:843-764-1788
Practice Address - Street 1:2713 DANTZLER DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9005
Practice Address - Country:US
Practice Address - Phone:843-764-1722
Practice Address - Fax:843-764-1788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3557Medicaid
SC20014778OtherSELECT HEALTH OF SC