Basic Information
| Provider Information | |||||||||
| NPI: | 1598263097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLANTATION PEDIARTICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1871 SAVAGE RD | ||||||||
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| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294074726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435319961 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1483 TOBIAS GADSON BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294074795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435319961 | ||||||||
| FaxNumber: | 8435319961 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2018 | ||||||||
| LastUpdateDate: | 01/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | ANGIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8437666308 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PLANTATION PEDIARTICS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.