Healthcare Provider Details

I. General information

NPI: 1245202217
Provider Name (Legal Business Name): SOUTHSIDE PEDIATRICS OF AIKEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 CENTRE SOUTH BLVD
AIKEN SC
29803-6319
US

IV. Provider business mailing address

206 CENTRE SOUTH BLVD
AIKEN SC
29803-6319
US

V. Phone/Fax

Practice location:
  • Phone: 803-642-9204
  • Fax: 803-648-3633
Mailing address:
  • Phone: 803-642-9204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11083
License Number StateSC

VIII. Authorized Official

Name: JONATHAN CLAUDE COLLINS
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 803-642-9204