Provider Demographics
NPI:1609259217
Name:EXPRESS PEDIATRIC CARE, P.A.
Entity Type:Organization
Organization Name:EXPRESS PEDIATRIC CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:POLLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-908-5797
Mailing Address - Street 1:2607 WOODRUFF RD
Mailing Address - Street 2:SUITE E #313
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-4803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:274 COMMONWEALTH DR
Practice Address - Street 2:SUITE C
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4869
Practice Address - Country:US
Practice Address - Phone:864-551-2422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28748208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC287488Medicaid