1144468083 NPI number — HIGHROAD PEDIATRICS, PA

Table of content: (NPI 1144468083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144468083 NPI number — HIGHROAD PEDIATRICS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGHROAD PEDIATRICS, 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:
KERNERSVILLE PEDIATRICS
Provider Other Organization Name Type Code:
3
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:
1144468083
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2808 MAPLEWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-4138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-765-9000
Provider Business Mailing Address Fax Number:
336-765-5702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 OLD WINSTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERNERSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27284-7121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-996-3001
Provider Business Practice Location Address Fax Number:
336-996-4687
Provider Enumeration Date:
01/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TOLLEY
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
ERIC
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
336-765-9000

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  36479 , 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: 5903823 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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