Basic Information
| Provider Information | |||||||||
| NPI: | 1003130493 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC ENDOCRINOLOGY & DIABETES SPECIALISTS | ||||||||
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| OtherOrganizationName: | PEDIATRIC ENDOCRINOLOGY & DIABETES SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19305 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282199305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046310002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1781 TATE BLVD SE | ||||||||
| Address2: | STE 203 | ||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286024251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045123636 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2010 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | RISSMILLER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | ENTERPRISE EVP | ||||||||
| AuthorizedOfficialTelephone: | 7043558675 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEDIATRIC ENDOCRINOLOGY & DIABETES SPECIALISTS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0205X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
No ID Information.