MEDICARE: ANGEL OAK PEDIATRICS LLC

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	261Q00000X	Clinic/Center
2	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1265207229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGEL OAK PEDIATRICS LLC

Provider Business Mailing Address
First Line	:	2911 WATERLEAF RD
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-3176
Country	:	US
Telephone Number	:	248-760-4587
Fax Number	:

Provider Business Practice Location Address
First Line	:	3312 MAYBANK HWY STE B
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-4818
Country	:	US
Telephone Number	:	843-894-3490
Fax Number	:	833-450-6022

Authorized Official
Title or Position	:	PEDIATRICIAN/OWNER
Name	:	DR. KELLI E JOHNSTON
Credential	:	DO
Telephone Number	:	248-760-4587

Provider Enumeration Date	:	11/20/2023
Last Update Date	:	05/28/2026

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