1396907903 NPI number — PEDIATRIC PRACTICE

Table of content: (NPI 1396907903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396907903 NPI number — PEDIATRIC PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC PRACTICE
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:
1396907903
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 41209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28309-1209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-609-6448
Provider Business Mailing Address Fax Number:
910-609-5070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 ROBESON ST STE 410
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28301-5520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-615-1885
Provider Business Practice Location Address Fax Number:
910-321-6254
Provider Enumeration Date:
06/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NAGOWSKI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
910-609-6700

Provider Taxonomy Codes

  • Taxonomy code: 2080P0205X , with the licence number:  H0213 , 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: PENDING , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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