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General NPI Number Information
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NPI Number | 1316996523
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Entity Type | Organization
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Legal Business Name | WHEATON PEDIATRICS LLC
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Dates
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Enumeration Date | 05/08/2006
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Last Update Date | 05/23/2016
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Provider Practice Location Address
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Address Line | 354 FOLLY RD SUITE #5
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City | CHARLESTON
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State | SC
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Zip | 29412-2594
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Country | US
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Telephone | 843-437-2545
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Fax |
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Provider Business Mailing Address
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Address Line | 6445 E BRIMLEY DR
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City | NAMPA
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State | ID
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Zip | 83687-4119
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Country | US
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Telephone | 843-437-2545
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MICHAEL JOHN WHEATON
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Credential | MD
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Telephone | 843-437-2545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 23312
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License Number State | SC
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