Provider Demographics
NPI:1679913651
Name:PINEVILLE PEDIATRICS,PLLC
Entity Type:Organization
Organization Name:PINEVILLE PEDIATRICS,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SATYA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMMALAMADAKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-540-3036
Mailing Address - Street 1:10700 KETTERING DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10700 KETTERING DR
Practice Address - Street 2:SUITE D
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3770
Practice Address - Country:US
Practice Address - Phone:704-540-3036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201001747261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916594Medicaid