1447303680 NPI number — SUBURBAN PEDIATRIC CLINIC, INC.

Table of content: (NPI 1447303680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447303680 NPI number — SUBURBAN PEDIATRIC CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUBURBAN PEDIATRIC CLINIC, INC.
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:
SUBURBAN PEDIATRIC CLINIC - DAVIDSON
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:
1447303680
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 SHILOH CHURCH RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
DAVIDSON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28036-7603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-439-3700
Provider Business Mailing Address Fax Number:
704-439-3729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 SHILOH CHURCH RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
DAVIDSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28036-7603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-439-3700
Provider Business Practice Location Address Fax Number:
704-439-3729
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LAYMON
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
F
Authorized Official Title or Position:
SR. VICE PRESIDENT
Authorized Official Telephone Number:
704-403-2276

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: 5903375 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5906983 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01491 . This is a "BCBS GROUP ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 896408 . This is a "MAMSI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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