Provider Demographics
NPI:1306805056
Name:CAROLINA PEDIATRICS & ADOLESCENT CARE, PA
Entity type:Organization
Organization Name:CAROLINA PEDIATRICS & ADOLESCENT CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:F
Authorized Official - Last Name:MUBARAK
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:803-256-0531
Mailing Address - Street 1:2113 ADAMS GRV
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6951
Mailing Address - Country:US
Mailing Address - Phone:803-256-0531
Mailing Address - Fax:803-765-9052
Practice Address - Street 1:2113 ADAMS GRV
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-7102
Practice Address - Country:US
Practice Address - Phone:803-256-0531
Practice Address - Fax:803-765-9052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12782208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0094Medicaid
SCI15359Medicare UPIN
SCH69100Medicare UPIN
SCF84862Medicare UPIN
SCB91342Medicare UPIN
SCGP0094Medicaid
SCA53452Medicare UPIN
SCI15358Medicare UPIN