Basic Information
| Provider Information | |||||||||
| NPI: | 1558546366 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDRENS COMMUNITY CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDRENS 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: | 90 SHENANGO ST STE 12 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161252060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245890290 | ||||||||
| FaxNumber: | 7245890293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2007 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | GIVENS | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7249331100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.