1083729701 NPI number — NORTHLAKE PEDIATRIC CARE PA

Table of content: (NPI 1083729701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083729701 NPI number — NORTHLAKE PEDIATRIC CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHLAKE PEDIATRIC CARE PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083729701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2117 SIMONTON RD
Provider Second Line Business Mailing Address:
SUITE 402
Provider Business Mailing Address City Name:
STATESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28625-8206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-871-2323
Provider Business Mailing Address Fax Number:
803-619-2149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2117 SIMONTON RD
Provider Second Line Business Practice Location Address:
SUITE 402
Provider Business Practice Location Address City Name:
STATESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28625-8206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-871-2323
Provider Business Practice Location Address Fax Number:
803-619-2149
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BORJA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-871-2323

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1002P . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 34D1014813 . This is a "CLIA ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5918872 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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