Provider Demographics
NPI:1447210976
Name:COLUMBUS PEDIATRICS & ADOLESCENT CARE PA
Entity Type:Organization
Organization Name:COLUMBUS PEDIATRICS & ADOLESCENT CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:COY
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-642-2642
Mailing Address - Street 1:800 JEFFERSON ST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-3702
Mailing Address - Country:US
Mailing Address - Phone:910-642-2642
Mailing Address - Fax:910-642-3346
Practice Address - Street 1:800 JEFFERSON ST
Practice Address - Street 2:SUITE 116
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3710
Practice Address - Country:US
Practice Address - Phone:910-642-2642
Practice Address - Fax:910-642-3346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36388261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902340Medicaid