Provider Demographics
NPI:1043270671
Name:CARRBORO PEDIATRICS AND INTERNAL MEDICINE, PA
Entity type:Organization
Organization Name:CARRBORO PEDIATRICS AND INTERNAL MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:ANNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-933-8381
Mailing Address - Street 1:127 FIDELITY ST
Mailing Address - Street 2:
Mailing Address - City:CARRBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27510-2002
Mailing Address - Country:US
Mailing Address - Phone:919-933-8381
Mailing Address - Fax:919-933-6623
Practice Address - Street 1:127 FIDELITY ST
Practice Address - Street 2:
Practice Address - City:CARRBORO
Practice Address - State:NC
Practice Address - Zip Code:27510-2002
Practice Address - Country:US
Practice Address - Phone:919-933-8381
Practice Address - Fax:919-933-6623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC83272207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0185TOtherBCBS OF NC
NC690185TMedicaid
NC690185TMedicaid