Provider Demographics
NPI:1083696041
Name:THE PEDIATRIC CENTER LLC
Entity Type:Organization
Organization Name:THE PEDIATRIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-451-1600
Mailing Address - Street 1:5900 WATERLOO ROAD,
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4147
Mailing Address - Country:US
Mailing Address - Phone:443-451-1600
Mailing Address - Fax:443-451-1619
Practice Address - Street 1:5900 WATERLOO RD STE 110
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2636
Practice Address - Country:US
Practice Address - Phone:443-451-1600
Practice Address - Fax:443-451-1619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD971721800Medicaid