Provider Demographics
NPI:1427125269
Name:GOLDSBORO PEDIATRICS PA
Entity type:Organization
Organization Name:GOLDSBORO PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:RIDDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-734-4736
Mailing Address - Street 1:2706 MEDICAL OFFICE PLACE
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9460
Mailing Address - Country:US
Mailing Address - Phone:919-734-4736
Mailing Address - Fax:919-580-1017
Practice Address - Street 1:2706 MEDICAL OFFICE PLACE
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9460
Practice Address - Country:US
Practice Address - Phone:919-734-4736
Practice Address - Fax:919-580-1017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38877208000000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01644OtherBCBS
NC8901644Medicaid
01644OtherBCBS