Healthcare Provider Details

I. General information

NPI: 1275523003
Provider Name (Legal Business Name): GREENSBORO CHILDREN'S DOCTOR, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 COLLEGE ROAD SUITE 11
GREENSBORO NC
27410-5150
US

IV. Provider business mailing address

515 COLLEGE ROAD SUITE 11
GREENSBORO NC
27410-5150
US

V. Phone/Fax

Practice location:
  • Phone: 336-852-9630
  • Fax: 336-852-9665
Mailing address:
  • Phone: 336-852-9630
  • Fax: 336-852-9665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27124
License Number StateNC

VIII. Authorized Official

Name: DR. RICHARD WALTERS BOETTE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 336-852-9630