Provider Demographics
NPI:1326078072
Name:PROVIDENCE PEDIATRICS
Entity Type:Organization
Organization Name:PROVIDENCE PEDIATRICS
Other - Org Name:PROVIDENCE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENTERPRISE EVP
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RISSMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-8675
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:704-631-0002
Mailing Address - Fax:
Practice Address - Street 1:14214 BALLANTYNE LAKE RD
Practice Address - Street 2:STE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3372
Practice Address - Country:US
Practice Address - Phone:704-364-3740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PEDIATRICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-04
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCE27995Medicaid
NC89013AKMedicaid