Provider Demographics
NPI:1316996523
Name:WHEATON PEDIATRICS LLC
Entity type:Organization
Organization Name:WHEATON PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WHEATON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-437-2545
Mailing Address - Street 1:6445 E BRIMLEY DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-4119
Mailing Address - Country:US
Mailing Address - Phone:843-437-2545
Mailing Address - Fax:
Practice Address - Street 1:354 FOLLY RD
Practice Address - Street 2:SUITE #5
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2594
Practice Address - Country:US
Practice Address - Phone:843-437-2545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23312208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4277Medicaid