Provider Demographics
NPI:1760682637
Name:GEORGETOWN PEDIATRIC CENTER, PC
Entity Type:Organization
Organization Name:GEORGETOWN PEDIATRIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:HLETKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-546-8686
Mailing Address - Street 1:PO BOX 618
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-0618
Mailing Address - Country:US
Mailing Address - Phone:843-546-8686
Mailing Address - Fax:843-546-1356
Practice Address - Street 1:57 JESSAMINE AVE
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-5837
Practice Address - Country:US
Practice Address - Phone:843-546-8686
Practice Address - Fax:843-546-1353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14532208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0557Medicaid
SCRHC031Medicaid