Provider Demographics
NPI:1083729701
Name:NORTHLAKE PEDIATRIC CARE PA
Entity Type:Organization
Organization Name:NORTHLAKE PEDIATRIC CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BORJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-871-2323
Mailing Address - Street 1:2117 SIMONTON RD
Mailing Address - Street 2:SUITE 402
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-8206
Mailing Address - Country:US
Mailing Address - Phone:704-871-2323
Mailing Address - Fax:803-619-2149
Practice Address - Street 1:2117 SIMONTON RD
Practice Address - Street 2:SUITE 402
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-8206
Practice Address - Country:US
Practice Address - Phone:704-871-2323
Practice Address - Fax:803-619-2149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1002POtherBCBS OF NC
34D1014813OtherCLIA ID
NC5918872Medicaid
NC=========OtherTAX ID NUMBER