Provider Demographics
NPI:1013334200
Name:GEORGETOWN PEDIATRIC CENTER
Entity Type:Organization
Organization Name:GEORGETOWN PEDIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:AMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
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:843-546-1353
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:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ84256Medicaid