Provider Demographics
NPI:1679589212
Name:CONCORD CHILDREN'S CLINIC
Entity Type:Organization
Organization Name:CONCORD CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANJU
Authorized Official - Middle Name:
Authorized Official - Last Name:SETHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-784-1010
Mailing Address - Street 1:1040 VINEHAVEN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025
Mailing Address - Country:US
Mailing Address - Phone:704-784-1010
Mailing Address - Fax:704-784-1013
Practice Address - Street 1:1040 VINEHAVEN DR,
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025
Practice Address - Country:US
Practice Address - Phone:704-784-1010
Practice Address - Fax:704-784-1013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015H6Medicaid
NC015H6OtherBCBS OF NC
NC=========OtherCOMMERCIALS