1003119553 NPI number — GROWING CHILD PEDIATRICS

Table of content: (NPI 1003119553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003119553 NPI number — GROWING CHILD PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GROWING CHILD PEDIATRICS
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:
1003119553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11130 CAPITAL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAKE FOREST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27587-4513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-488-4094
Provider Business Mailing Address Fax Number:
919-488-4096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 GATEWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAYTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27520-2158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-585-9001
Provider Business Practice Location Address Fax Number:
919-488-1719
Provider Enumeration Date:
12/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CUNA
Authorized Official First Name:
DESI
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BILLING
Authorized Official Telephone Number:
919-488-0015

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6006881 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 890137Q , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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