1992724181 NPI number — NORTHSIDE PEDIATRICS PC

Table of content: (NPI 1992724181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992724181 NPI number — NORTHSIDE PEDIATRICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSIDE PEDIATRICS PC
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:
1992724181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 28690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23228-8690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-432-4631
Provider Business Mailing Address Fax Number:
877-331-0645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2008 BREMO RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23226-2443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-288-0814
Provider Business Practice Location Address Fax Number:
877-331-0645
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
LAKEITA
Authorized Official Middle Name:
LYNNE
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
804-432-4631

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0101231186 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0101231186 . This is a "VA LICENSE NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010167175 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1710963582 . This is a "LAKEITA L. SMITH'S NPI" identifier . This identifiers is of the category "OTHER".




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