1194769992 NPI number — UNIVERSITY PEDIATRICS

Table of content: (NPI 1194769992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194769992 NPI number — UNIVERSITY PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY PEDIATRICS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194769992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 MEDICAL PARK
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29203-6843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-255-3410
Provider Business Mailing Address Fax Number:
803-256-0977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8301 FARROW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203-3245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-935-5604
Provider Business Practice Location Address Fax Number:
803-935-5380
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
R.
Authorized Official Middle Name:
CAUGHMAN
Authorized Official Title or Position:
CHAIR
Authorized Official Telephone Number:
803-434-7950

Provider Taxonomy Codes

  • Taxonomy code: 2080P0006X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DRC001 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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