Provider Demographics
NPI:1497523625
Name:GOLDSBORO PEDIATRICS PA
Entity Type:Organization
Organization Name:GOLDSBORO PEDIATRICS PA
Other - Org Name:LAGRANGE PEDIATRICS PA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:RIDDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-734-4736
Mailing Address - Street 1:114 E RAILROAD STREET
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:NC
Mailing Address - Zip Code:28551
Mailing Address - Country:US
Mailing Address - Phone:252-566-5999
Mailing Address - Fax:252-566-4430
Practice Address - Street 1:114 E RAILROAD STREET
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:NC
Practice Address - Zip Code:28551
Practice Address - Country:US
Practice Address - Phone:252-566-5999
Practice Address - Fax:252-566-4430
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOLDSBORO PEDIATRICS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-12-18
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901644Medicaid