Provider Demographics
NPI:1336127570
Name:KINGS MOUNTAIN PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:KINGS MOUNTAIN PEDIATRIC CLINIC
Other - Org Name:KINGS MOUNTAIN PEDIATRICS, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:STALLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-739-2521
Mailing Address - Street 1:108 EDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-2702
Mailing Address - Country:US
Mailing Address - Phone:704-739-2521
Mailing Address - Fax:704-739-4314
Practice Address - Street 1:108 EDGEMONT DR
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-2702
Practice Address - Country:US
Practice Address - Phone:704-739-2521
Practice Address - Fax:704-739-4314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19089208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8979192Medicaid
NC79192OtherBLUE CROSS BLUE SHIELD