Provider Demographics
NPI:1083490981
Name:PEDIATRIC AND ADOLESCENT MEDICINE OF CHESHIRE, LLC
Entity Type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT MEDICINE OF CHESHIRE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHINCHILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-272-2382
Mailing Address - Street 1:677 S MAIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3161
Mailing Address - Country:US
Mailing Address - Phone:203-272-2382
Mailing Address - Fax:203-272-0071
Practice Address - Street 1:677 S MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3161
Practice Address - Country:US
Practice Address - Phone:203-272-2382
Practice Address - Fax:203-272-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty