Basic Information
| Provider Information | |||||||||
| NPI: | 1235322983 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC SERVICES OF AMERICA, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PSA HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 TECHNOLOGY PKWY | ||||||||
| Address2: | |||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300922932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704411580 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16 PEARL ST | ||||||||
| Address2: | |||||||||
| City: | WELLSBORO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169011500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707245989 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2007 | ||||||||
| LastUpdateDate: | 08/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | VALENTINE | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7702488757 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 03080501 | PA | Y | Agencies | Home Health |
No ID Information.