MEDICARE: HIGHROAD PEDIATRICS, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	36479	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144468083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGHROAD PEDIATRICS, PA

Provider Business Mailing Address
First Line	:	2808 MAPLEWOOD AVE
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-4138
Country	:	US
Telephone Number	:	336-765-9000
Fax Number	:	336-765-5702

Provider Business Practice Location Address
First Line	:	815 OLD WINSTON RD
Second Line	:
City	:	KERNERSVILLE
State	:	NC
Zip	:	27284-7121
Country	:	US
Telephone Number	:	336-996-3001
Fax Number	:	336-996-4687

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MR. SCOTT ERIC TOLLEY
Credential	:
Telephone Number	:	336-765-9000

Provider Enumeration Date	:	01/30/2009
Last Update Date	:	01/30/2009

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