Healthcare Provider Details

I. General information

NPI: 1699964569
Provider Name (Legal Business Name): CHILDREN'S RESPIRATORY CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 BEAR DR
GREENVILLE SC
29605-4458
US

IV. Provider business mailing address

58 BEAR DR
GREENVILLE SC
29605-4458
US

V. Phone/Fax

Practice location:
  • Phone: 864-220-8000
  • Fax: 864-220-8009
Mailing address:
  • Phone: 864-220-8000
  • Fax: 864-220-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number11118
License Number StateSC

VIII. Authorized Official

Name: DR. GUY SAMUEL FASCIANA
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 864-220-8000