Basic Information
| Provider Information | |||||||||
| NPI: | 1770927345 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIA HEALTHCARE, LLC | ||||||||
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| OtherOrganizationName: | AVEANNA HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 INTERSTATE NORTH PKWY SE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702488740 | ||||||||
| FaxNumber: | 7702488192 | ||||||||
| Practice Location | |||||||||
| Address1: | 1183 JACKS RUN RD | ||||||||
| Address2: | |||||||||
| City: | NORTH VERSAILLES | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151370000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123496708 | ||||||||
| FaxNumber: | 4123496716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2013 | ||||||||
| LastUpdateDate: | 11/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | WHITESIDE | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, REGULATORY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 7702488740 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM3000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medically Fragile Intants and Children Day Care |
ID Information
| ID | Type | State | Issuer | Description | 1021992800016 | 05 | PA | MEDICAID |