Basic Information
| Provider Information | |||||||||
| NPI: | 1124568688 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHERN HOSPTIAL OF SURRY COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHERN PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1267 | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270301267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367838911 | ||||||||
| FaxNumber: | 3367192492 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N POINTE BLVD | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270302266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367896267 | ||||||||
| FaxNumber: | 3367864245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2017 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING AND CONTRACTING COORD | ||||||||
| AuthorizedOfficialTelephone: | 3367838911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.