Healthcare Provider Details

I. General information

NPI: 1396907903
Provider Name (Legal Business Name): PEDIATRIC PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 ROBESON ST STE 410
FAYETTEVILLE NC
28301-5520
US

IV. Provider business mailing address

PO BOX 41209
FAYETTEVILLE NC
28309-1209
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-1885
  • Fax: 910-321-6254
Mailing address:
  • Phone: 910-609-6448
  • Fax: 910-609-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberH0213
License Number StateNC

VIII. Authorized Official

Name: MR. MICHAEL NAGOWSKI
Title or Position: CEO
Credential:
Phone: 910-609-6700