Provider Demographics
NPI:1609058056
Name:SURF PEDIATRICS AND MEDICINE PC
Entity Type:Organization
Organization Name:SURF PEDIATRICS AND MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:THOR
Authorized Official - Last Name:LIGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-449-5200
Mailing Address - Street 1:5107 N CROATAN HWY
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3989
Mailing Address - Country:US
Mailing Address - Phone:252-255-5321
Mailing Address - Fax:252-565-0534
Practice Address - Street 1:5107 N CROATAN HWY STE 101
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-3989
Practice Address - Country:US
Practice Address - Phone:252-255-5321
Practice Address - Fax:252-565-0534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002-00943208000000X
NC200200943261QP2300X
NC0010-01994363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916879Medicaid