Provider Demographics
NPI:1548424104
Name:OWEN PARK PEDIATRICS, PA
Entity Type:Organization
Organization Name:OWEN PARK PEDIATRICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:O
Authorized Official - Last Name:ADHOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-860-3500
Mailing Address - Street 1:1520 OWEN PARK LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3454
Mailing Address - Country:US
Mailing Address - Phone:910-860-3500
Mailing Address - Fax:910-485-3507
Practice Address - Street 1:1520 OWEN PARK LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3454
Practice Address - Country:US
Practice Address - Phone:910-860-3500
Practice Address - Fax:910-485-3507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911931Medicaid