Basic Information
| Provider Information | |||||||||
| NPI: | 1184060469 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S COMMUNITY CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CHILDREN'S COMMUNITY PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11279 PERRY HWY | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150909381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249331100 | ||||||||
| FaxNumber: | 7249331160 | ||||||||
| Practice Location | |||||||||
| Address1: | 4022 ZUCK RD | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165064592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148775424 | ||||||||
| FaxNumber: | 8148775423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2013 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | GIVENS | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7249331100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.