Healthcare Provider Details

I. General information

NPI: 1609058056
Provider Name (Legal Business Name): SURF PEDIATRICS AND MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5107 N CROATAN HWY STE 101
KITTY HAWK NC
27949-3989
US

IV. Provider business mailing address

5107 N CROATAN HWY
KITTY HAWK NC
27949-3989
US

V. Phone/Fax

Practice location:
  • Phone: 252-255-5321
  • Fax: 252-565-0534
Mailing address:
  • Phone: 252-255-5321
  • Fax: 252-565-0534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2002-00943
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number200200943
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01994
License Number StateNC

VIII. Authorized Official

Name: DR. CHRISTIAN THOR LIGE
Title or Position: PEDIATRICIAN
Credential: M.D.
Phone: 252-449-5200