Basic Information
| Provider Information | |||||||||
| NPI: | 1619495926 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDEN'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 STE 450 | ||||||||
| Address2: | |||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150909303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249331100 | ||||||||
| FaxNumber: | 7249331160 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 N BROAD STREET EXT STE 5 | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161275805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244585872 | ||||||||
| FaxNumber: | 7244585972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2017 | ||||||||
| LastUpdateDate: | 09/07/2017 | ||||||||
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| AuthorizedOfficialLastName: | GIVENS | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE ADMINISTRATOR II | ||||||||
| 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.