Basic Information
Provider Information | |||||||||
NPI: | 1649441205 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEDIATRIA HEALTHCARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5185 PEACHTREE PKWY | ||||||||
Address2: | STE 350 | ||||||||
City: | NORCROSS | ||||||||
State: | GA | ||||||||
PostalCode: | 300926542 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708401966 | ||||||||
FaxNumber: | 7708401901 | ||||||||
Practice Location | |||||||||
Address1: | 8101 WASHINGTON LN | ||||||||
Address2: | SUITE 250 | ||||||||
City: | WYNCOTE | ||||||||
State: | PA | ||||||||
PostalCode: | 190951625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2153766516 | ||||||||
FaxNumber: | 2153766520 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2008 | ||||||||
LastUpdateDate: | 03/22/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DIGNAN | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
AuthorizedOfficialTelephone: | 7708401966 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PEDIATRIA HEALTHCARE, LLC | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | ATTORNEY | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 3310501 | PA | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 102199280 0003 | 05 | PA |   | MEDICAID |