Healthcare Provider Details

I. General information

NPI: 1376535799
Provider Name (Legal Business Name): THE PEDIATRIC PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 ROBESON ST SUITE 300
FAYETTEVILLE NC
28301-5552
US

IV. Provider business mailing address

PO BOX 41209
FAYETTEVILLE NC
28309-1209
US

V. Phone/Fax

Practice location:
  • Phone: 910-609-1616
  • Fax: 910-609-1619
Mailing address:
  • Phone: 910-609-6448
  • Fax: 910-609-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberH0213
License Number StateNC

VIII. Authorized Official

Name: MR. RICHARD H PARKS
Title or Position: CEO
Credential:
Phone: 910-609-6700