Provider Demographics
NPI:1982716858
Name:RUTHERFORD PEDIATRICS PA
Entity Type:Organization
Organization Name:RUTHERFORD PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFRY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ARCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-286-9149
Mailing Address - Street 1:141 TRYON ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139-3036
Mailing Address - Country:US
Mailing Address - Phone:828-286-9049
Mailing Address - Fax:828-286-5596
Practice Address - Street 1:141 TRYON ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-3036
Practice Address - Country:US
Practice Address - Phone:828-286-9049
Practice Address - Fax:828-286-5596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39115208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02692OtherBCBS
NC8902692Medicaid