1093250904 NPI number — PEDIATRIC HOUSECALL SERVICES PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093250904 NPI number — PEDIATRIC HOUSECALL SERVICES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC HOUSECALL SERVICES PLLC
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:
1093250904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6401 STARGAZE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28269-0802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-607-3483
Provider Business Mailing Address Fax Number:
704-464-1818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1899 TATE BLVD SE
Provider Second Line Business Practice Location Address:
SUITE 2108
Provider Business Practice Location Address City Name:
HICKORY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28602-4200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-327-6500
Provider Business Practice Location Address Fax Number:
828-327-4700
Provider Enumeration Date:
01/01/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DUMOND
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
704-607-3483

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  200200214 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89135HH , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com