Healthcare Provider Details

I. General information

NPI: 1043270671
Provider Name (Legal Business Name): CARRBORO PEDIATRICS AND INTERNAL MEDICINE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 FIDELITY ST
CARRBORO NC
27510-2002
US

IV. Provider business mailing address

127 FIDELITY ST
CARRBORO NC
27510-2002
US

V. Phone/Fax

Practice location:
  • Phone: 919-933-8381
  • Fax: 919-933-6623
Mailing address:
  • Phone: 919-933-8381
  • Fax: 919-933-6623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number83272
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number83272
License Number StateNC

VIII. Authorized Official

Name: DR. CORY LYN ANNIS
Title or Position: PRESIDENT
Credential: MD
Phone: 919-933-8381