Provider Demographics
NPI:1700864428
Name:EVERGREEN PEDIATRICS SOLUTIONS, PC
Entity Type:Organization
Organization Name:EVERGREEN PEDIATRICS SOLUTIONS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-425-1565
Mailing Address - Street 1:3114 CROASDAILE DR STE 200
Mailing Address - Street 2:EVERGREEN PEDIATRIC SOLUTIONS, PC
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2508
Mailing Address - Country:US
Mailing Address - Phone:919-425-1565
Mailing Address - Fax:919-425-0478
Practice Address - Street 1:1 BAY AVE
Practice Address - Street 2:EVERGREEN PEDIATRIC SOLUTIONS, PC
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4837
Practice Address - Country:US
Practice Address - Phone:973-237-5795
Practice Address - Fax:919-425-0478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0079481Medicaid
NJ0079481Medicaid