1700864428 NPI number — EVERGREEN PEDIATRICS SOLUTIONS, PC

Table of content: (NPI 1700864428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700864428 NPI number — EVERGREEN PEDIATRICS SOLUTIONS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN PEDIATRICS SOLUTIONS, PC
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:
1700864428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3114 CROASDAILE DR STE 200
Provider Second Line Business Mailing Address:
EVERGREEN PEDIATRIC SOLUTIONS, PC
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27705-2508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-425-1565
Provider Business Mailing Address Fax Number:
919-425-0478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 BAY AVE
Provider Second Line Business Practice Location Address:
EVERGREEN PEDIATRIC SOLUTIONS, PC
Provider Business Practice Location Address City Name:
MONTCLAIR
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07042-4837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-237-5795
Provider Business Practice Location Address Fax Number:
919-425-0478
Provider Enumeration Date:
01/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
919-425-1565

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: 0079481 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".