Healthcare Provider Details

I. General information

NPI: 1437102381
Provider Name (Legal Business Name): CENTER FOR PEDIATRICS AND ADOLESCENT MEDICINE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 GATEWAY BLVD STE A
MOORESVILLE NC
28117-5608
US

IV. Provider business mailing address

136 GATEWAY BLVD STE A
MOORESVILLE NC
28117-5608
US

V. Phone/Fax

Practice location:
  • Phone: 704-799-2878
  • Fax: 704-799-1627
Mailing address:
  • Phone: 704-799-2878
  • Fax: 704-799-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number118445
License Number StateNC

VIII. Authorized Official

Name: DR. ELIZABETH ELLEN TILT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 704-799-2878