Basic Information
Provider Information | |||||||||
NPI: | 1922430966 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHILDREN'S COMMUNITY CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHILDREN'S COMMUNITY PEDIATRICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11279 PERRY HWY | ||||||||
Address2: | SUITE 450 | ||||||||
City: | WEXFORD | ||||||||
State: | PA | ||||||||
PostalCode: | 150909381 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7249331100 | ||||||||
FaxNumber: | 7249331160 | ||||||||
Practice Location | |||||||||
Address1: | 800 S LOGAN BLVD | ||||||||
Address2: | SUITE 1200 | ||||||||
City: | HOLLIDAYSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 166483051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8149467568 | ||||||||
FaxNumber: | 8149437490 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2013 | ||||||||
LastUpdateDate: | 04/24/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GIVENS | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 7249331100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.