MEDICARE: INDIAN LAND PEDIATRICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1306118583
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIAN LAND PEDIATRICS, LLC

Provider Business Mailing Address
First Line	:	7580 CHARLOTTE HWY
Second Line	:	SUITE 1000
City	:	FORT MILL
State	:	SC
Zip	:	29707-7801
Country	:	US
Telephone Number	:	803-396-1090
Fax Number	:	803-396-1091

Provider Business Practice Location Address
First Line	:	7580 CHARLOTTE HWY
Second Line	:	SUITE 1000
City	:	FORT MILL
State	:	SC
Zip	:	29707-7801
Country	:	US
Telephone Number	:	803-396-1090
Fax Number	:	803-396-1091

Authorized Official
Title or Position	:	OWNER
Name	:	LUCRETIA ANN CARTER
Credential	:	MD
Telephone Number	:	803-396-1090

Provider Enumeration Date	:	02/02/2012
Last Update Date	:	11/27/2012

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