Provider Demographics
NPI:1174640163
Name:PEDIATRIC SURGICAL ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:PEDIATRIC SURGICAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-370-0223
Mailing Address - Street 1:1900 RANDOLPH RD
Mailing Address - Street 2:STE. 210
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1106
Mailing Address - Country:US
Mailing Address - Phone:704-370-0223
Mailing Address - Fax:704-370-0799
Practice Address - Street 1:1900 RANDOLPH RD
Practice Address - Street 2:STE 210
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1106
Practice Address - Country:US
Practice Address - Phone:704-370-0223
Practice Address - Fax:704-370-0799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC731202086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890182WMedicaid
SCNPA716Medicaid