Basic Information
| Provider Information | |||||||||
| NPI: | 1396907903 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC PRACTICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAPE FEAR VALLEY PEDIATRIC ENDOCRINOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 41209 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283091209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106096448 | ||||||||
| FaxNumber: | 9106095070 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 ROBESON ST | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283015552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106091688 | ||||||||
| FaxNumber: | 9103216254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 06/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | NAGOWSKI | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9106096700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0205X | H0213 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NC | MEDICAID |