Provider Demographics
NPI:1275173031
Name:PG COMMUNITYPEDIATRIC AND ADOLESCENT HEALTH CENTER INC.
Entity Type:Organization
Organization Name:PG COMMUNITYPEDIATRIC AND ADOLESCENT HEALTH CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MODUPE
Authorized Official - Middle Name:F
Authorized Official - Last Name:ODUNUGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-322-2411
Mailing Address - Street 1:8420 VICTORY LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-3562
Mailing Address - Country:US
Mailing Address - Phone:301-980-6417
Mailing Address - Fax:
Practice Address - Street 1:6122 LANDOVER RD
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1016
Practice Address - Country:US
Practice Address - Phone:301-322-2411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty