Provider Demographics
NPI:1245550821
Name:MONCKS CORNER PEDIATRICS LLC
Entity type:Organization
Organization Name:MONCKS CORNER PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:WEST
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:843-761-2000
Mailing Address - Street 1:5000 EPSON PLANTATION DR STE B
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3979
Mailing Address - Country:US
Mailing Address - Phone:843-761-2000
Mailing Address - Fax:843-761-2267
Practice Address - Street 1:5000 EPSON PLANTATION DR STE B
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3979
Practice Address - Country:US
Practice Address - Phone:843-761-2000
Practice Address - Fax:843-761-2267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC188Medicaid
SCC68743Medicare UPIN