Provider Demographics
NPI:1093915662
Name:THE PEDIATRIC EXPRESS PA
Entity Type:Organization
Organization Name:THE PEDIATRIC EXPRESS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:B
Authorized Official - Last Name:GALLENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:919-477-5152
Mailing Address - Street 1:PO BOX 15133
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0133
Mailing Address - Country:US
Mailing Address - Phone:919-477-5152
Mailing Address - Fax:413-618-3203
Practice Address - Street 1:6402 MCCRIMMON PARKWAY
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27560
Practice Address - Country:US
Practice Address - Phone:919-477-5152
Practice Address - Fax:413-618-3203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCI17580Medicare UPIN