Basic Information
| Provider Information | |||||||||
| NPI: | 1346311925 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC CARDIOLOGY ASSOC PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CONGENITAL HEART | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 US ROUTE 1 | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078835532 | ||||||||
| FaxNumber: | 2078835552 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 US ROUTE 1 | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078835532 | ||||||||
| FaxNumber: | 2078835552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 08/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | DONNELLY | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | PATRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2078835532 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | 014324 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 112590000 | 05 | ME | MEDICAID | 30004962 | 05 | NH | MEDICAID |