1811024979 NPI number — EASTERN PEDIATRICS, P.A.

Table of content: (NPI 1811024979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811024979 NPI number — EASTERN PEDIATRICS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN PEDIATRICS, P.A.
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:
1811024979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 STONEHENGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27858-5067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-561-7777
Provider Business Mailing Address Fax Number:
252-561-7778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 STONEHENGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27858-5067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-561-7777
Provider Business Practice Location Address Fax Number:
252-561-7778
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAY
Authorized Official First Name:
YOICHA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
ADMINISTRATIVE/FINANCIAL SUPERVISOR
Authorized Official Telephone Number:
252-561-7777

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  970062 , 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: 5950204 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2348101 . This is a "MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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