Provider Demographics
NPI:1194954420
Name:HALCZENKO, PAUL WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:WILLIAM
Last Name:HALCZENKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 RAVEN RD
Mailing Address - Street 2:
Mailing Address - City:HANAHAN
Mailing Address - State:SC
Mailing Address - Zip Code:29410-8509
Mailing Address - Country:US
Mailing Address - Phone:321-246-2705
Mailing Address - Fax:
Practice Address - Street 1:295 MIDLAND PKWY
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8104
Practice Address - Country:US
Practice Address - Phone:843-970-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1583262080P0203X
SC905152080P0203X
PA4264792080P0203X
IN01071583A2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH862ZOtherMEDICARE PTAN
FL001393000Medicaid