Healthcare Provider Details

I. General information

NPI: 1093250904
Provider Name (Legal Business Name): PEDIATRIC HOUSECALL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2017
Last Update Date: 01/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1899 TATE BLVD SE SUITE 2108
HICKORY NC
28602-4200
US

IV. Provider business mailing address

6401 STARGAZE LN
CHARLOTTE NC
28269-0802
US

V. Phone/Fax

Practice location:
  • Phone: 828-327-6500
  • Fax: 828-327-4700
Mailing address:
  • Phone: 704-607-3483
  • Fax: 704-464-1818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200200214
License Number StateNC

VII. Legacy identifiers

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

# 1
Identifier89135HH
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: DR. DAVID JOHN DUMOND
Title or Position: CHIEF OPERATING OFFICER
Credential: DPT
Phone: 704-607-3483