Provider Demographics
NPI:1992701445
Name:SOUTHFORK PEDIATRICS, PLLC
Entity type:Organization
Organization Name:SOUTHFORK PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-726-1379
Mailing Address - Street 1:1733 CONNELLY SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-7827
Mailing Address - Country:US
Mailing Address - Phone:828-726-8885
Mailing Address - Fax:828-726-8883
Practice Address - Street 1:1733 CONNELLY SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-7827
Practice Address - Country:US
Practice Address - Phone:828-726-8885
Practice Address - Fax:828-726-8883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701479261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891141RMedicaid
NCB0324OtherMEDCOST
NC1141ROtherBCBS OF NC
NC2359139OtherUNITED HEALTH CARE
NC891141ROtherCAROLINA ACCESS
NC1467112OtherCIGNA
NC=========OtherGREAT WEST
NC2359139OtherUNITED HEALTH CARE
NC=========OtherEVOLUTIONS
NC1141ROtherBCBS OF NC
NC=========OtherHEALTH CARE SAVINGS
NCB0324OtherMEDCOST
NC891141RMedicaid