MEDICARE: OAKBROOK PEDIATRICS, PA

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

General Provider Information

NPI Number	:	1760456909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAKBROOK PEDIATRICS, PA

Provider Business Mailing Address
First Line	:	1801 TROLLEY RD
Second Line	:	STE 202
City	:	SUMMERVILLE
State	:	SC
Zip	:	29485-8283
Country	:	US
Telephone Number	:	843-871-2588
Fax Number	:	843-871-1664

Provider Business Practice Location Address
First Line	:	1801 TROLLEY RD
Second Line	:	STE 202
City	:	SUMMERVILLE
State	:	SC
Zip	:	29485-8283
Country	:	US
Telephone Number	:	843-871-2588
Fax Number	:	843-871-1664

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARY KATE TILLMAN
Credential	:	M.D.
Telephone Number	:	843-871-2588

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	08/22/2020

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