Basic Information
| Provider Information | |||||||||
| NPI: | 1427415298 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLANTATION PEDIATRICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1871 SAVAGE RD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294074726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437666308 | ||||||||
| FaxNumber: | 8438049883 | ||||||||
| Practice Location | |||||||||
| Address1: | 1871 SAVAGE RD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294074726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437666308 | ||||||||
| FaxNumber: | 8438049883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2016 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | RADABAUGH | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8437666308 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | GP7269 | 05 | SC | MEDICAID |