Provider Demographics
NPI:1083652630
Name:PIEDMONT PEDIATRICS LLC
Entity type:Organization
Organization Name:PIEDMONT PEDIATRICS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-833-5654
Mailing Address - Street 1:996 MEDICAL RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325
Mailing Address - Country:US
Mailing Address - Phone:864-833-5654
Mailing Address - Fax:864-833-2786
Practice Address - Street 1:996 MEDICAL RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325
Practice Address - Country:US
Practice Address - Phone:864-833-5654
Practice Address - Fax:864-833-2786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X, 208000000X
SCAPN699208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1856Medicaid
SCRHC152Medicaid