Healthcare Provider Details

I. General information

NPI: 1487612628
Provider Name (Legal Business Name): KIDS CARE PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 KELLIE DR
SMITHFIELD NC
27577-9443
US

IV. Provider business mailing address

101 KELLIE DR
SMITHFIELD NC
27577-9443
US

V. Phone/Fax

Practice location:
  • Phone: 919-938-3749
  • Fax: 919-938-3795
Mailing address:
  • Phone: 919-938-3749
  • Fax: 919-938-3795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number147337
License Number StateNC
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier8902042
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: DR. DEBRA J TETREAULT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 919-938-3749