Healthcare Provider Details

I. General information

NPI: 1932521630
Provider Name (Legal Business Name): COVENANT PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2014
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MATTHEWS ST SUITE 800
MATTHEWS NC
28105-4866
US

IV. Provider business mailing address

101 E MATTHEWS ST SUITE 800
MATTHEWS NC
28105-4866
US

V. Phone/Fax

Practice location:
  • Phone: 704-321-5700
  • Fax: 704-321-5701
Mailing address:
  • Phone: 704-321-5700
  • Fax: 704-321-5701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200301456
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number200301456
License Number StateNC

VIII. Authorized Official

Name: DR. ANTHONIA OGECHI EMEZIE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 704-321-5700