Provider Demographics
NPI:1962481531
Name:PALMETTO PEDIATRICS OF CONWAY
Entity Type:Organization
Organization Name:PALMETTO PEDIATRICS OF CONWAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:RABON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-234-5678
Mailing Address - Street 1:171 WACCAMAW MEDICAL PARK CT
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8965
Mailing Address - Country:US
Mailing Address - Phone:843-234-5678
Mailing Address - Fax:843-234-4567
Practice Address - Street 1:171 WACCAMAW MEDICAL PARK CT
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8965
Practice Address - Country:US
Practice Address - Phone:843-234-5678
Practice Address - Fax:843-234-4567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22576174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4121Medicaid
SCI29483Medicare UPIN
SCGP4121Medicaid