Provider Demographics
NPI:1144468083
Name:HIGHROAD PEDIATRICS, PA
Entity type:Organization
Organization Name:HIGHROAD PEDIATRICS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:TOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-765-9000
Mailing Address - Street 1:2808 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4138
Mailing Address - Country:US
Mailing Address - Phone:336-765-9000
Mailing Address - Fax:336-765-5702
Practice Address - Street 1:815 OLD WINSTON RD
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7121
Practice Address - Country:US
Practice Address - Phone:336-996-3001
Practice Address - Fax:336-996-4687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36479208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903823Medicaid