Provider Demographics
NPI:1265207229
Name:ANGEL OAK PEDIATRICS LLC
Entity type:Organization
Organization Name:ANGEL OAK PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIAATRICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-760-4587
Mailing Address - Street 1:2911 WATERLEAF RD
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-3176
Mailing Address - Country:US
Mailing Address - Phone:248-760-4587
Mailing Address - Fax:
Practice Address - Street 1:1834 BLUEBIRD RD OFC 7
Practice Address - Street 2:
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-8308
Practice Address - Country:US
Practice Address - Phone:843-894-3490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-20
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty