Provider Demographics
NPI:1124191911
Name:PEDIATRICARE, INC.
Entity Type:Organization
Organization Name:PEDIATRICARE, INC.
Other - Org Name:ABC PEDIATRICARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, PEDIATRICARE, INC.
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:MORTON
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-923-1505
Mailing Address - Street 1:8601 VETERANS HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1547
Mailing Address - Country:US
Mailing Address - Phone:410-923-1505
Mailing Address - Fax:410-923-6323
Practice Address - Street 1:8601 VETERANS HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1547
Practice Address - Country:US
Practice Address - Phone:410-923-1505
Practice Address - Fax:410-923-6323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDO 2016208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD32574Medicare UPIN