Provider Demographics
NPI:1356300248
Name:SANFORD PEDIATRICS, P.A.
Entity Type:Organization
Organization Name:SANFORD PEDIATRICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TOMMIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:ANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-774-7117
Mailing Address - Street 1:1801 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-5067
Mailing Address - Country:US
Mailing Address - Phone:919-774-7117
Mailing Address - Fax:919-776-6715
Practice Address - Street 1:1801 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-5067
Practice Address - Country:US
Practice Address - Phone:919-774-7117
Practice Address - Fax:919-776-6715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902612Medicaid