Provider Demographics
NPI:1275788416
Name:GROVE PARK PEDIATRICS
Entity Type:Organization
Organization Name:GROVE PARK PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARITA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-570-0354
Mailing Address - Street 1:113 TRAIL ONE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-5531
Mailing Address - Country:US
Mailing Address - Phone:336-570-0354
Mailing Address - Fax:336-570-0356
Practice Address - Street 1:113 TRAIL ONE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5531
Practice Address - Country:US
Practice Address - Phone:336-570-0354
Practice Address - Fax:336-570-0356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-00119208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89137W6Medicaid
NC89137W6Medicaid
FL32823Medicare PIN