Provider Demographics
NPI:1871577197
Name:KINSTON PEDIATRIC ASSOCIATES PA
Entity type:Organization
Organization Name:KINSTON PEDIATRIC ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-522-0335
Mailing Address - Street 1:PO BOX 1419
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28503
Mailing Address - Country:US
Mailing Address - Phone:252-522-0335
Mailing Address - Fax:252-522-4016
Practice Address - Street 1:2509 NORTH QUEEN ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28502
Practice Address - Country:US
Practice Address - Phone:252-522-0335
Practice Address - Fax:252-522-4016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
O1980OtherBLUE CROSS BLUE SHIELD
NC8901980Medicaid