Basic Information
| Provider Information | |||||||||
| NPI: | 1255660353 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRIANGLE CHILD ABUSE PEDIATRIC SERVICES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1689 | ||||||||
| Address2: | |||||||||
| City: | ETOWAH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287291689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288915524 | ||||||||
| FaxNumber: | 8288914069 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 NAVAHO DR | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276097319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198454620 | ||||||||
| FaxNumber: | 9198468126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2009 | ||||||||
| LastUpdateDate: | 05/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | EVERETT | ||||||||
| AuthorizedOfficialFirstName: | VIVIAN | ||||||||
| AuthorizedOfficialMiddleName: | DENISE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9198454620 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080C0008X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Child Abuse Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 5913571 | 05 | NC | MEDICAID |