Provider Demographics
NPI:1144591595
Name:THE PEDIATRIC CARE CENTER LLC
Entity Type:Organization
Organization Name:THE PEDIATRIC CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEYINKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-589-4501
Mailing Address - Street 1:780 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-3920
Mailing Address - Country:US
Mailing Address - Phone:860-589-4501
Mailing Address - Fax:860-589-4502
Practice Address - Street 1:780 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-3920
Practice Address - Country:US
Practice Address - Phone:860-589-4501
Practice Address - Fax:860-589-4502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038949174400000X
CT002742363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1528120094Medicaid
CT1679736870Medicaid