Basic Information
| Provider Information | |||||||||
| NPI: | 1992802607 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIX MEDICAL GROUP OF SOUTH CAROLINA PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4991 LAKE BROOK DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230609293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043463535 | ||||||||
| FaxNumber: | 8042530408 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 CONCORD TER | ||||||||
| Address2: | |||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543840175 | ||||||||
| FaxNumber: | 9548511948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 08/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | POOLE | ||||||||
| AuthorizedOfficialFirstName: | ARNOLD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED SIGNATOR | ||||||||
| AuthorizedOfficialTelephone: | 9543840175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP0179 | 05 | SC | MEDICAID | GP3457 | 05 | SC | MEDICAID | GP3519 | 05 | SC | MEDICAID | GP2505 | 05 | SC | MEDICAID | GP2701 | 05 | SC | MEDICAID | GP1787 | 05 | SC | MEDICAID | GP2096 | 05 | SC | MEDICAID | GP3250 | 05 | SC | MEDICAID | GP3458 | 05 | SC | MEDICAID | GP2351 | 05 | SC | MEDICAID |