1124356019 NPI number — SALISBURY PEDIATRIC ASSOCIATES, PA

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 1124356019 NPI number — SALISBURY PEDIATRIC ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALISBURY PEDIATRIC ASSOCIATES, 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:
Provider Other Organization Name Type Code:
6
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:
1124356019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
129 WOODSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28144-3255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-636-5576
Provider Business Mailing Address Fax Number:
704-216-2011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17810 STATESVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 311
Provider Business Practice Location Address City Name:
CORNELIUS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28031-8148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-655-6300
Provider Business Practice Location Address Fax Number:
704-655-7997
Provider Enumeration Date:
12/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
AVERITT
Authorized Official First Name:
SHEPARD
Authorized Official Middle Name:
SEWELL
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
704-216-2020

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , 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: 8902597 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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