Provider Demographics
NPI:1760453450
Name:PRIME PEDIATRICS INC
Entity Type:Organization
Organization Name:PRIME PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MEDHAVINI
Authorized Official - Middle Name:H
Authorized Official - Last Name:DHANDHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-437-9600
Mailing Address - Street 1:PO BOX 25756
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5012
Mailing Address - Country:US
Mailing Address - Phone:910-437-9600
Mailing Address - Fax:910-437-9801
Practice Address - Street 1:3415B MELROSE ROAD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304
Practice Address - Country:US
Practice Address - Phone:910-437-9600
Practice Address - Fax:910-437-9801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401399208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7928785Medicaid
NC7928785Medicaid