Basic Information
| Provider Information | |||||||||
| NPI: | 1063653178 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTOVER PEDIATRICS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 400 LIBERTY HILL RD | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283582446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107388060 | ||||||||
| FaxNumber: | 9106713600 | ||||||||
| Practice Location | |||||||||
| Address1: | 3551 DUNN RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | EASTOVER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283128794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107388060 | ||||||||
| FaxNumber: | 9106713600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2009 | ||||||||
| LastUpdateDate: | 03/19/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUCKWORTH | ||||||||
| AuthorizedOfficialFirstName: | ROSE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9107388060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHILDREN'S HEALTH OF CAROLINA | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPC, CMIS, CMOM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.