Provider Demographics
NPI:1811995111
Name:THE PEDIATRIC CLINIC, P.A.
Entity type:Organization
Organization Name:THE PEDIATRIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:C
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-536-2725
Mailing Address - Street 1:940 HOLLY ST NE
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-4930
Mailing Address - Country:US
Mailing Address - Phone:803-536-2725
Mailing Address - Fax:803-534-1441
Practice Address - Street 1:940 HOLLY ST NE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4930
Practice Address - Country:US
Practice Address - Phone:803-536-2725
Practice Address - Fax:803-534-1441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0966Medicaid