Basic Information
| Provider Information | |||||||||
| NPI: | 1285146258 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC HEALTH CARE ASSOCIATES PC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHCA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CENTENNIAL DR | ||||||||
| Address2: | |||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019607938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785351110 | ||||||||
| FaxNumber: | 9785352907 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 CENTENNIAL DR | ||||||||
| Address2: | |||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019607938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785351110 | ||||||||
| FaxNumber: | 9785352907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2017 | ||||||||
| LastUpdateDate: | 10/31/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARDING | ||||||||
| AuthorizedOfficialFirstName: | DEBORA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7817293008 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEDIATRIC HEALTH CARE ASSOCIATES, PC | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 110070794A | 05 | MA | MEDICAID |