Provider Demographics
NPI:1073943668
Name:PEDIATRIC WALK IN CARE LLC
Entity Type:Organization
Organization Name:PEDIATRIC WALK IN CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HEMANT
Authorized Official - Middle Name:K
Authorized Official - Last Name:PANCHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-749-7603
Mailing Address - Street 1:141 B HAZARD AVENUE
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-5412
Mailing Address - Country:US
Mailing Address - Phone:860-749-7603
Mailing Address - Fax:860-749-7604
Practice Address - Street 1:141 B HAZARD AVENUE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-5412
Practice Address - Country:US
Practice Address - Phone:860-749-7603
Practice Address - Fax:860-749-7604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032413208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001324136Medicaid