Provider Demographics
NPI:1558415844
Name:THE PEDIATRIC CENTER
Entity Type:Organization
Organization Name:THE PEDIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:AZIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANDNOOSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-848-7005
Mailing Address - Street 1:111 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-1518
Mailing Address - Country:US
Mailing Address - Phone:864-848-7004
Mailing Address - Fax:864-848-3666
Practice Address - Street 1:111 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-1518
Practice Address - Country:US
Practice Address - Phone:864-848-7004
Practice Address - Fax:864-848-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18570208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT26745Medicaid
SCG27959Medicare UPIN