Provider Demographics
NPI:1609102649
Name:UNIVERSITY PEDIATRICS
Entity Type:Organization
Organization Name:UNIVERSITY PEDIATRICS
Other - Org Name:UNIVERSITY PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LAYMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-446-8250
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:704-631-0002
Mailing Address - Fax:
Practice Address - Street 1:10545 BLAIR RD
Practice Address - Street 2:SUITE 3200
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-2800
Practice Address - Country:US
Practice Address - Phone:704-863-9550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY PEDIATRICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-27
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908366Medicaid