Healthcare Provider Details

I. General information

NPI: 1447303680
Provider Name (Legal Business Name): SUBURBAN PEDIATRIC CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 SHILOH CHURCH RD SUITE 101
DAVIDSON NC
28036-7603
US

IV. Provider business mailing address

2101 SHILOH CHURCH RD SUITE 101
DAVIDSON NC
28036-7603
US

V. Phone/Fax

Practice location:
  • Phone: 704-439-3700
  • Fax: 704-439-3729
Mailing address:
  • Phone: 704-439-3700
  • Fax: 704-439-3729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5903375
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier5906983
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 3
Identifier01491
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS GROUP ID
# 4
Identifier896408
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerMAMSI

VIII. Authorized Official

Name: THOMAS F LAYMON
Title or Position: SR. VICE PRESIDENT
Credential:
Phone: 704-403-2276