Provider Demographics
NPI:1285847459
Name:MARION PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:MARION PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PEDIATRICS
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAMSHED
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-652-6386
Mailing Address - Street 1:31 E MEDICAL CT STE 1
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NC
Mailing Address - Zip Code:28752-4969
Mailing Address - Country:US
Mailing Address - Phone:828-652-6386
Mailing Address - Fax:
Practice Address - Street 1:31 E MEDICAL CT STE 1
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-4969
Practice Address - Country:US
Practice Address - Phone:828-652-6386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001405473174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902077Medicaid