Provider Demographics
NPI:1487616520
Name:SUBURBAN PEDIATRIC CLINIC, INC
Entity type:Organization
Organization Name:SUBURBAN PEDIATRIC CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:LAYMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-2276
Mailing Address - Street 1:3396 CLOVERLEAF PKWY
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-6992
Mailing Address - Country:US
Mailing Address - Phone:704-403-7740
Mailing Address - Fax:704-403-7750
Practice Address - Street 1:3396 CLOVERLEAF PKWY
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-6992
Practice Address - Country:US
Practice Address - Phone:704-403-7740
Practice Address - Fax:704-403-7750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906978Medicaid
NC896408OtherMAMSI
NC6901491Medicaid
NC01491OtherBCBS GROUP ID
NC5906978Medicaid
NC6901491Medicaid