Basic Information
| Provider Information | |||||||||
| NPI: | 1073693347 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTERN CAROLINA PEDIATRICS PA | ||||||||
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| OtherOrganizationName: | EASTERN CAROLINA PEDIATRICS PA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1702 MEDICAL PARK DR W | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278932705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522437944 | ||||||||
| FaxNumber: | 2522436097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1702 MEDICAL PARK DR W | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278932705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522437944 | ||||||||
| FaxNumber: | 2522436097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2522437944 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 890120E | 05 | NC | MEDICAID |