Provider Demographics
NPI:1083676373
Name:CENTRAL GREENE PEDIATRICS, PC
Entity Type:Organization
Organization Name:CENTRAL GREENE PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-627-0926
Mailing Address - Street 1:246 ELM DR
Mailing Address - Street 2:
Mailing Address - City:WAYNESBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15370-8269
Mailing Address - Country:US
Mailing Address - Phone:724-627-0926
Mailing Address - Fax:
Practice Address - Street 1:246 ELM DR
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:PA
Practice Address - Zip Code:15370-8269
Practice Address - Country:US
Practice Address - Phone:724-627-0926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072957L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH33903Medicare UPIN
PA046748Medicare ID - Type Unspecified