Healthcare Provider Details

I. General information

NPI: 1760547335
Provider Name (Legal Business Name): CLEMSONSENECA PEDIATRIC & ADOLESCENT MEDICINE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 MAIN ST
SENECA SC
29678-3245
US

IV. Provider business mailing address

207 MAIN ST
SENECA SC
29678-3245
US

V. Phone/Fax

Practice location:
  • Phone: 864-888-4222
  • Fax: 864-888-0023
Mailing address:
  • Phone: 864-888-4222
  • Fax: 864-888-0023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10252
License Number StateSC

VIII. Authorized Official

Name: DR. JORDAN A DEAN JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 864-888-4222