Basic Information
| Provider Information | |||||||||
| NPI: | 1891708699 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VEGA HEALTHCARE INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HAMPTON PEDIATRICS AND FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 JACKSON AVE E | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299243602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039433813 | ||||||||
| FaxNumber: | 8039435971 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 JACKSON AVE E | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299243602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039433813 | ||||||||
| FaxNumber: | 8039435971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RYAN | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8039433813 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 23033 | SC | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | 28595 | SC | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | GP4422 | 05 | SC | MEDICAID |