Healthcare Provider Details

I. General information

NPI: 1750458428
Provider Name (Legal Business Name): KNOX PEDIATRICS OF BRUNSWICK, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL CAMPUS DR. SUITE 207
SUPPLY NC
28462-4094
US

IV. Provider business mailing address

20 MEDICAL CAMPUS DR. SUITE 207
SUPPLY NC
28462-4092
US

V. Phone/Fax

Practice location:
  • Phone: 910-755-5066
  • Fax: 910-755-5099
Mailing address:
  • Phone: 910-755-5066
  • Fax: 910-755-5099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number16200
License Number StateNC

VIII. Authorized Official

Name: ANGELINA EDRALIN KNOX
Title or Position: ADMINISTRATOR
Credential: MD
Phone: 910-763-3349