Healthcare Provider Details

I. General information

NPI: 1558415844
Provider Name (Legal Business Name): THE PEDIATRIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MEMORIAL DR
GREER SC
29650-1518
US

IV. Provider business mailing address

111 MEMORIAL DR
GREER SC
29650-1518
US

V. Phone/Fax

Practice location:
  • Phone: 864-848-7004
  • Fax: 864-848-3666
Mailing address:
  • Phone: 864-848-7004
  • Fax: 864-848-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18570
License Number StateSC

VII. Legacy identifiers

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

# 1
IdentifierT26745
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: DR. AZIZ GHANDNOOSH
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 864-848-7005