Healthcare Provider Details

I. General information

NPI: 1366403792
Provider Name (Legal Business Name): TRI-COUNTY PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 AMENDMENT AVE SUITE 102
ROCK HILL SC
29732-3036
US

IV. Provider business mailing address

165 AMENDMENT AVENUE SUITE 102
ROCK HILL SC
29732-2730
US

V. Phone/Fax

Practice location:
  • Phone: 803-329-2700
  • Fax: 803-329-2788
Mailing address:
  • Phone: 803-329-2700
  • Fax: 803-329-2788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22018
License Number StateSC

VIII. Authorized Official

Name: GAURANG C SHAH
Title or Position: MANAGING PHYSICIAN
Credential: M.D.
Phone: 803-329-2700