Provider Demographics
NPI:1609906676
Name:KIDS CENTRAL PEDIATRICS, INC.
Entity type:Organization
Organization Name:KIDS CENTRAL PEDIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:JAMES III
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-483-5678
Mailing Address - Street 1:575 OAK RIDGE TPKE STE 120
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-7173
Mailing Address - Country:US
Mailing Address - Phone:865-483-5678
Mailing Address - Fax:865-483-4027
Practice Address - Street 1:575 OAK RIDGE TPKE STE 120
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-7173
Practice Address - Country:US
Practice Address - Phone:865-483-5678
Practice Address - Fax:865-483-4027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000033918261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4035193OtherBLUECARE TENNCARE
TN4035193OtherBLUE CROSS BLUE SHIELD
TN4035193OtherTENNCARE SELECT
TN4035193OtherTENNCARE SELECT