1114041043 NPI number — THE PEDIATRIC GROUP

Table of content: (NPI 1114041043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114041043 NPI number — THE PEDIATRIC GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PEDIATRIC GROUP
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:
1114041043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3323
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28680-3323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-443-0163
Provider Business Mailing Address Fax Number:
828-264-2550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
867 SKI ACRES DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOWING ROCK
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28605-9237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-443-0163
Provider Business Practice Location Address Fax Number:
828-264-2550
Provider Enumeration Date:
03/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PERKINS
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
828-443-0163

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1251 , 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: 0788W . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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