1013976505 NPI number — PEDIATRIC ENDOCRINE SPECIALTY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013976505 NPI number — PEDIATRIC ENDOCRINE SPECIALTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC ENDOCRINE SPECIALTY
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:
1013976505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 NE MEDICAL PARK
Provider Second Line Business Mailing Address:
SUITE 212
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29223-6251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-865-6008
Provider Business Mailing Address Fax Number:
803-865-6018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 NE MEDICAL PARK
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223-6251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-865-6008
Provider Business Practice Location Address Fax Number:
803-865-6018
Provider Enumeration Date:
03/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEIZE
Authorized Official First Name:
HOWARD
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
803-865-6008

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  19871 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP3583 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19871 . This is a "DR. HEIZE'S SC MED LIC #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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