1992701445 NPI number — SOUTHFORK PEDIATRICS, PLLC

Table of content: (NPI 1992701445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992701445 NPI number — SOUTHFORK PEDIATRICS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHFORK PEDIATRICS, PLLC
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:
1992701445
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1733 CONNELLY SPRINGS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LENOIR
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28645-7827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-726-8885
Provider Business Mailing Address Fax Number:
828-726-8883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1733 CONNELLY SPRINGS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LENOIR
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28645-7827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-726-8885
Provider Business Practice Location Address Fax Number:
828-726-8883
Provider Enumeration Date:
06/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
828-726-1379

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  9701479 , 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: 891141R , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: B0324 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1141R . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2359139 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 891141R . This is a "CAROLINA ACCESS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1467112 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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