Provider Demographics
NPI:1205013331
Name:ROCKINGHAM CHILDRENS CLINIC
Entity Type:Organization
Organization Name:ROCKINGHAM CHILDRENS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELTON
Authorized Official - Middle Name:PHELPHS
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-627-1141
Mailing Address - Street 1:705 S VAN BUREN RD
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5321
Mailing Address - Country:US
Mailing Address - Phone:336-627-1141
Mailing Address - Fax:336-627-1163
Practice Address - Street 1:705 S VAN BUREN RD
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5321
Practice Address - Country:US
Practice Address - Phone:336-627-1141
Practice Address - Fax:336-627-1163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17478208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6758860Medicaid
NC5902560Medicaid