MEDICARE: CHARLESTON PEDIATRICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician		SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013965474
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLESTON PEDIATRICS

Provider Business Mailing Address
First Line	:	198 RUTLEDGE AVE
Second Line	:	SUITE 1
City	:	CHARLESTON
State	:	SC
Zip	:	29403-5817
Country	:	US
Telephone Number	:	843-723-0855
Fax Number	:	843-723-1307

Provider Business Practice Location Address
First Line	:	198 RUTLEDGE AVE
Second Line	:	SUITE 1
City	:	CHARLESTON
State	:	SC
Zip	:	29403-5817
Country	:	US
Telephone Number	:	843-723-0855
Fax Number	:	843-723-1307

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. THOMAS GODFREY QUATTLEBAUM
Credential	:	M.D.
Telephone Number	:	843-723-0855

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	07/10/2007

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Directions to “CHARLESTON PEDIATRICS ” Practice Location

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