NPIMap

Organization Active NPI

Pediatric Surgical Associates, P.a.

  • Pediatric Surgery Physician
  • Charlotte, NC
National Provider Identifier
1174640163
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Surgery PhysicianTaxonomy code 2086S0120X
License
73120 Issued in NC
Legal business name
PEDIATRIC SURGICAL ASSOCIATES, P.A.
Practice address
1900 Randolph Rd
Ste 210
Charlotte, NC 28207-1106
Phone
(704) 370-0223
Fax
(704) 370-0799
NPI assigned
Mar 23, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Linda G. Boyd
Title
Administrator
Phone
(704) 370-0223

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Surgery PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2086S0120X 73120 NC Primary

Addresses

Primary practice location

1900 Randolph Rd
Ste 210
Charlotte, NC 28207-1106

Mailing address

1900 Randolph Rd
Ste. 210
Charlotte, NC 28207-1106
Phone (704) 370-0223

Other identifiers 2

IdentifierTypeStateIssuer
890182WMedicaidNC
NPA716MedicaidSC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050725001084 NC Part B Supplier - Clinic/Group Practice 9537196159 Receives reassigned benefits from 5 practitioners
Practice locations: Charlotte, NC

National Provider Directory

National Provider Directory

Locations

1900 Randolph Rd
Ste 210
Charlotte, NC 28207
Phone (704) 370-0223

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174608000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1174640163",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1900 RANDOLPH RD",
            "address_2": "STE. 210",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282071106",
            "telephone_number": "704-370-0223",
            "fax_number": "704-370-0799"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1900 RANDOLPH RD",
            "address_2": "STE 210",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282071106",
            "telephone_number": "704-370-0223",
            "fax_number": "704-370-0799"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC SURGICAL ASSOCIATES, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-23",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BOYD",
        "authorized_official_first_name": "LINDA",
        "authorized_official_middle_name": "G.",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "704-370-0223",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "2086S0120X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Surgery, Pediatric Surgery",
            "state": "NC",
            "license": "73120",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "890182W",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "NPA716",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Charlotte, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.