Provider Demographics
NPI:1114228475
Name:MOSES CONE AFFILIATED PHYSICIANS, INC.
Entity Type:Organization
Organization Name:MOSES CONE AFFILIATED PHYSICIANS, INC.
Other - Org Name:PREMIER PEDIATRICS OF EDEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-832-8005
Mailing Address - Street 1:509 S VAN BUREN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5082
Mailing Address - Country:US
Mailing Address - Phone:336-627-5437
Mailing Address - Fax:336-627-1681
Practice Address - Street 1:509 S VAN BUREN RD
Practice Address - Street 2:SUITE B
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5082
Practice Address - Country:US
Practice Address - Phone:336-627-5437
Practice Address - Fax:336-627-1681
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MOSES H. CONE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-03
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916799Medicaid