Provider Demographics
NPI:1164534731
Name:PEDIATRIC ASSOCIATES, PA
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MACOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-368-8612
Mailing Address - Street 1:4735 OGLETOWN STANTON RD
Mailing Address - Street 2:MAP 2 SUITE 1116
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2072
Mailing Address - Country:US
Mailing Address - Phone:302-368-8612
Mailing Address - Fax:302-368-8836
Practice Address - Street 1:4735 OGLETOWN STANTON RD
Practice Address - Street 2:MAP 2 SUITE 1116
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2072
Practice Address - Country:US
Practice Address - Phone:302-368-8612
Practice Address - Fax:302-368-8836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1989014003208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE75682001OtherAMERIHEALTH GROUP
DE78530OtherAETNA GROUP
DE0075682000OtherIBC GROUP
DE0000079002OtherIBC GROUP
DE0075682000OtherIBC GROUP