Healthcare Provider Details

I. General information

NPI: 1740673946
Provider Name (Legal Business Name): RAINBOW KIDS PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

853 DURHAM RD SUITE B
WAKE FOREST NC
27587-8793
US

IV. Provider business mailing address

853 DURHAM RD SUITE B
WAKE FOREST NC
27587-8793
US

V. Phone/Fax

Practice location:
  • Phone: 919-435-1099
  • Fax: 919-435-1130
Mailing address:
  • Phone: 919-435-1099
  • Fax: 919-435-1130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9901171
License Number StateNC

VII. Legacy identifiers

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

# 1
Identifier229108
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerUNITED
# 2
Identifier8912588
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 3
Identifier331532
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerWELLPATH
# 4
Identifier1258X
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS

VIII. Authorized Official

Name: GENEVIEVE SANATRA FAISON-ALSTON
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 919-435-1099