Provider Demographics
NPI:1447303680
Name:SUBURBAN PEDIATRIC CLINIC, INC.
Entity type:Organization
Organization Name:SUBURBAN PEDIATRIC CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:LAYMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-2276
Mailing Address - Street 1:2101 SHILOH CHURCH RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7603
Mailing Address - Country:US
Mailing Address - Phone:704-439-3700
Mailing Address - Fax:704-439-3729
Practice Address - Street 1:2101 SHILOH CHURCH RD
Practice Address - Street 2:SUITE 101
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7603
Practice Address - Country:US
Practice Address - Phone:704-439-3700
Practice Address - Fax:704-439-3729
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUBURBAN PEDIATRIC CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-19
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903375Medicaid
NC5906983Medicaid
NC01491OtherBCBS GROUP ID
NC896408OtherMAMSI
NC=========OtherGROUP TAX ID
NC=========002OtherTRICARE STANDARD, NON NWK