Healthcare Provider Details

I. General information

NPI: 1760682637
Provider Name (Legal Business Name): GEORGETOWN PEDIATRIC CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 03/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 JESSAMINE AVE
GEORGETOWN SC
29440-5837
US

IV. Provider business mailing address

PO BOX 618
GEORGETOWN SC
29442-0618
US

V. Phone/Fax

Practice location:
  • Phone: 843-546-8686
  • Fax: 843-546-1353
Mailing address:
  • Phone: 843-546-8686
  • Fax: 843-546-1356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14532
License Number StateSC

VIII. Authorized Official

Name: PAUL J HLETKO
Title or Position: PRESIDENT
Credential: MD
Phone: 843-546-8686