Healthcare Provider Details

I. General information

NPI: 1124356019
Provider Name (Legal Business Name): SALISBURY PEDIATRIC ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2009
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17810 STATESVILLE RD SUITE 311
CORNELIUS NC
28031-8148
US

IV. Provider business mailing address

129 WOODSON ST
SALISBURY NC
28144-3255
US

V. Phone/Fax

Practice location:
  • Phone: 704-655-6300
  • Fax: 704-655-7997
Mailing address:
  • Phone: 704-636-5576
  • Fax: 704-216-2011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: MR. SHEPARD SEWELL AVERITT IV
Title or Position: ADMINISTRATOR
Credential: MED.
Phone: 704-216-2020