Provider Demographics
NPI:1427016138
Name:ROXBORO INTERNAL MEDICINE & PEDIATRICS, P.A.
Entity Type:Organization
Organization Name:ROXBORO INTERNAL MEDICINE & PEDIATRICS, P.A.
Other - Org Name:ROXBORO MEDPEDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-598-0002
Mailing Address - Street 1:796 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4571
Mailing Address - Country:US
Mailing Address - Phone:336-598-0002
Mailing Address - Fax:336-599-2159
Practice Address - Street 1:796 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4571
Practice Address - Country:US
Practice Address - Phone:336-598-0002
Practice Address - Fax:336-599-2159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34464207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901102Medicaid
NC8901102Medicaid
NC2325776Medicare PIN
NCG06446Medicare UPIN