Basic Information
| Provider Information | |||||||||
| NPI: | 1366983637 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRIBE513, P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PARKSIDE PEDIATRICS | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 525 VERDAE BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296074021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642720388 | ||||||||
| FaxNumber: | 8642139237 | ||||||||
| Practice Location | |||||||||
| Address1: | 312 HARRISON BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296807133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642720388 | ||||||||
| FaxNumber: | 8642139237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2017 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OOSTDYK | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | COORDINATOR, PROVIDER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8642720388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.