=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275788416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROVE PARK PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2008
-----------------------------------------------------
Last Update Date | 12/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 TRAIL ONE
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-5531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-570-0354
-----------------------------------------------------
Fax | 336-570-0356
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 TRAIL ONE
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-5531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-570-0354
-----------------------------------------------------
Fax | 336-570-0356
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARGARITA GOLDAR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 336-570-0354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 2004-00119
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------