Provider Demographics
NPI:1932521630
Name:COVENANT PEDIATRICS PA
Entity Type:Organization
Organization Name:COVENANT PEDIATRICS PA
Other - Org Name:SHILOH MEDICALS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONIA
Authorized Official - Middle Name:OGECHI
Authorized Official - Last Name:EMEZIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-321-5700
Mailing Address - Street 1:101 E MATTHEWS ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-4866
Mailing Address - Country:US
Mailing Address - Phone:704-321-5700
Mailing Address - Fax:704-321-5701
Practice Address - Street 1:101 E MATTHEWS ST
Practice Address - Street 2:SUITE 800
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-4866
Practice Address - Country:US
Practice Address - Phone:704-321-5700
Practice Address - Fax:704-321-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301456208000000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty