Healthcare Provider Details

I. General information

NPI: 1013976505
Provider Name (Legal Business Name): PEDIATRIC ENDOCRINE SPECIALTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NE MEDICAL PARK SUITE 212
COLUMBIA SC
29223-6251
US

IV. Provider business mailing address

3000 NE MEDICAL PARK SUITE 212
COLUMBIA SC
29223-6251
US

V. Phone/Fax

Practice location:
  • Phone: 803-865-6008
  • Fax: 803-865-6018
Mailing address:
  • Phone: 803-865-6008
  • Fax: 803-865-6018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number19871
License Number StateSC

VIII. Authorized Official

Name: DR. HOWARD J. HEIZE
Title or Position: PHYSICIAN
Credential: M. D.
Phone: 803-865-6008