Provider Demographics
NPI:1316227739
Name:SHALOM PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:SHALOM PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RITA
Authorized Official - Middle Name:OBIAGELI
Authorized Official - Last Name:NNAEMEKAOKOYEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-574-8355
Mailing Address - Street 1:2806 RANDLEMAN RD
Mailing Address - Street 2:SUITE M
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-5265
Mailing Address - Country:US
Mailing Address - Phone:336-574-8355
Mailing Address - Fax:336-273-9192
Practice Address - Street 1:2806 RANDLEMAN RD
Practice Address - Street 2:SUITE M
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-5265
Practice Address - Country:US
Practice Address - Phone:336-574-8355
Practice Address - Fax:336-273-9192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01548261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4188Medicaid