Provider Demographics
NPI:1124135603
Name:OUR CHILDREN'S CLINIC, PA
Entity type:Organization
Organization Name:OUR CHILDREN'S CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:G
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-355-3773
Mailing Address - Street 1:4024A OLD TAR RD
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-8430
Mailing Address - Country:US
Mailing Address - Phone:252-355-3773
Mailing Address - Fax:252-355-1958
Practice Address - Street 1:4024A OLD TAR RD
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-8430
Practice Address - Country:US
Practice Address - Phone:252-355-3773
Practice Address - Fax:252-355-1958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0264EOtherBCBS OF NC
NC890264EMedicaid