Basic Information
| Provider Information | |||||||||
| NPI: | 1124086814 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS ACUTE CARE OF FAYETTEVILLE, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 N BUFFALO DR | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891283636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023957095 | ||||||||
| FaxNumber: | 7023953502 | ||||||||
| Practice Location | |||||||||
| Address1: | 1638 OWEN DR - PICU | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106153182 | ||||||||
| FaxNumber: | 9106153176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 02/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | GIOIA | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7023957095 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 5913396 | 05 | NC | MEDICAID |