Provider Demographics
NPI:1225158405
Name:PEDIATRIC PROFESSIONAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:PEDIATRIC PROFESSIONAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:978-683-1974
Mailing Address - Street 1:413 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-2022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:413 BROADWAY
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-2022
Practice Address - Country:US
Practice Address - Phone:978-683-1974
Practice Address - Fax:978-689-9710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D87994Medicare UPIN
D88219Medicare UPIN
D88397Medicare UPIN
A37593Medicare UPIN