Provider Demographics
NPI:1356403612
Name:MIDLANDS PEDIATRICS PA
Entity type:Organization
Organization Name:MIDLANDS PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DOLLISON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:803-254-4257
Mailing Address - Street 1:2712 MIDDLEBURG DRIVE
Mailing Address - Street 2:SUITE #101
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2415
Mailing Address - Country:US
Mailing Address - Phone:803-254-4257
Mailing Address - Fax:803-252-7334
Practice Address - Street 1:2712 MIDDLEBURG DRIVE
Practice Address - Street 2:SUITE #101
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2415
Practice Address - Country:US
Practice Address - Phone:803-254-4257
Practice Address - Fax:803-252-7334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP 3475Medicaid