Provider Demographics
NPI:1730270448
Name:FAYETTEVILLE CHILDREN'S CLINIC, P.A.
Entity type:Organization
Organization Name:FAYETTEVILLE CHILDREN'S CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HUSKE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-484-3121
Mailing Address - Street 1:PO BOX 53127
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-3127
Mailing Address - Country:US
Mailing Address - Phone:910-484-3121
Mailing Address - Fax:910-484-9027
Practice Address - Street 1:1606 MORGANTON RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-4738
Practice Address - Country:US
Practice Address - Phone:910-484-3121
Practice Address - Fax:910-484-9027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39028208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0235GOtherBLUE CROSS BLUE SHIELD
NC790235GMedicaid