Healthcare Provider Details

I. General information

NPI: 1609066273
Provider Name (Legal Business Name): JOHNSTON COUNTY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BERKSHIRE RD
SMITHFIELD NC
27577
US

IV. Provider business mailing address

PO BOX 570
SMITHFIELD NC
27577-0570
US

V. Phone/Fax

Practice location:
  • Phone: 919-934-0564
  • Fax: 919-934-9703
Mailing address:
  • Phone: 919-934-0564
  • Fax: 919-934-9703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29813
License Number StateNC

VII. Legacy identifiers

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

# 1
Identifier89014WJ
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MS. SALLY LAWSON CARPENTER
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 919-934-0564