Healthcare Provider Details

I. General information

NPI: 1306805056
Provider Name (Legal Business Name): CAROLINA PEDIATRICS & ADOLESCENT CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 10/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 ADAMS GRV SUITE 101
COLUMBIA SC
29203-7102
US

IV. Provider business mailing address

2113 ADAMS GRV SUITE 101
COLUMBIA SC
29203-6951
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-0531
  • Fax: 803-765-9052
Mailing address:
  • Phone: 803-256-0531
  • Fax: 803-765-9052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12782
License Number StateSC

VIII. Authorized Official

Name: DR. PHILIP F. MUBARAK
Title or Position: PHYSICIAN
Credential: M. D.
Phone: 803-256-0531