Provider Demographics
NPI:1003866716
Name:LAUREL PEDIATRIC ASSOCIATES INC
Entity Type:Organization
Organization Name:LAUREL PEDIATRIC ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNIE
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:BARTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-262-9500
Mailing Address - Street 1:323 BUDFIELD STREET
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-3219
Mailing Address - Country:US
Mailing Address - Phone:814-262-9500
Mailing Address - Fax:814-262-7303
Practice Address - Street 1:323 BUDFIELD STREET
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3219
Practice Address - Country:US
Practice Address - Phone:814-262-9500
Practice Address - Fax:814-262-7303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000849373OtherHIGHMARK GROUP PROV. NUMB
PA0018019370001Medicaid