Healthcare Provider Details

I. General information

NPI: 1023077211
Provider Name (Legal Business Name): FAITH PEDIATRICS AND ADOLESCENT MEDICINE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 SIX FORKS RD
RALEIGH NC
27609-7233
US

IV. Provider business mailing address

3350 SIX FORKS RD
RALEIGH NC
27609-7233
US

V. Phone/Fax

Practice location:
  • Phone: 919-881-9440
  • Fax: 919-881-9465
Mailing address:
  • Phone: 919-881-9440
  • Fax: 919-881-9465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CONNELL COVINGTON
Title or Position: PHYSICIAN
Credential: MD
Phone: 919-881-9440