Healthcare Provider Details

I. General information

NPI: 1265400469
Provider Name (Legal Business Name): FOOTHILLS PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 ENTERPRISE DR
EASLEY SC
29642-8280
US

IV. Provider business mailing address

290 ENTERPRISE DR
EASLEY SC
29642-8280
US

V. Phone/Fax

Practice location:
  • Phone: 864-220-1110
  • Fax: 864-220-1104
Mailing address:
  • Phone: 864-220-1110
  • Fax: 864-220-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierGP3241
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: MS. FREDDA LEE MONROE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 864-220-1110