Provider Demographics
NPI:1750458428
Name:KNOX PEDIATRICS OF BRUNSWICK, PLLC
Entity Type:Organization
Organization Name:KNOX PEDIATRICS OF BRUNSWICK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELINA
Authorized Official - Middle Name:EDRALIN
Authorized Official - Last Name:KNOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-763-3349
Mailing Address - Street 1:20 MEDICAL CAMPUS DR.
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-4092
Mailing Address - Country:US
Mailing Address - Phone:910-755-5066
Mailing Address - Fax:910-755-5099
Practice Address - Street 1:20 MEDICAL CAMPUS DR.
Practice Address - Street 2:SUITE 207
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4094
Practice Address - Country:US
Practice Address - Phone:910-755-5066
Practice Address - Fax:910-755-5099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1841218716OtherNPI
NC8949897Medicaid
NC5903109Medicaid
NC5903109Medicaid