Provider Demographics
NPI:1720226236
Name:PREMIER PEDIATRICS, PA
Entity Type:Organization
Organization Name:PREMIER PEDIATRICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PETINA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SLOAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-246-2229
Mailing Address - Street 1:135 TURNER ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-7054
Mailing Address - Country:US
Mailing Address - Phone:910-246-2229
Mailing Address - Fax:910-246-0237
Practice Address - Street 1:135 TURNER ST
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-7054
Practice Address - Country:US
Practice Address - Phone:910-246-2229
Practice Address - Fax:910-246-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20070048363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89013C9Medicaid