Provider Demographics
NPI:1457718835
Name:DAVIS GROVE PEDIATRICS PLLC
Entity Type:Organization
Organization Name:DAVIS GROVE PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:YAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:919-452-4761
Mailing Address - Street 1:204 DAVIS GROVE CIR STE 107
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-2581
Mailing Address - Country:US
Mailing Address - Phone:919-363-3427
Mailing Address - Fax:919-363-3437
Practice Address - Street 1:204 DAVIS GROVE CIR STE 107
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-2581
Practice Address - Country:US
Practice Address - Phone:919-363-3427
Practice Address - Fax:919-363-3437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00550208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910793Medicaid