Healthcare Provider Details

I. General information

NPI: 1184016941
Provider Name (Legal Business Name): SOUTH CAROLINA PEDIATRICS ALLIANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CLEMSON RD
COLUMBIA SC
29229-4341
US

IV. Provider business mailing address

601 CLEMSON RD
COLUMBIA SC
29229-4341
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-6146
  • Fax: 803-462-0312
Mailing address:
  • Phone: 803-788-6146
  • Fax: 803-462-0312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAH GRUBBS
Title or Position: CFO
Credential:
Phone: 803-788-6146