Basic Information
Provider Information
NPI: 1053445817
EntityType: 2
ReplacementNPI:  
OrganizationName: SEACOAST PEDIATRICS
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 776 DANIEL ELLIS DR
Address2: SUITE 2 A
City: CHARLESTON
State: SC
PostalCode: 294123094
CountryCode: US
TelephoneNumber: 8437958100
FaxNumber: 8437223010
Practice Location
Address1: 776 DANIEL ELLIS DR
Address2: SUITE 2 A
City: CHARLESTON
State: SC
PostalCode: 294123094
CountryCode: US
TelephoneNumber: 8437958100
FaxNumber: 8437223010
Other Information
ProviderEnumerationDate: 03/15/2007
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: GEILS
AuthorizedOfficialFirstName: MEGHAN
AuthorizedOfficialMiddleName: ODOM
AuthorizedOfficialTitleorPosition: SECRETARY
AuthorizedOfficialTelephone: 8437958100
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
173000000X19333SCY193400000X SINGLE SPECIALTY GROUPOther Service ProvidersLegal Medicine 

ID Information
IDTypeStateIssuerDescription
GP321405SC MEDICAID


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