Provider Demographics
NPI:1275749566
Name:COMMUNITY PEDIATRICS SC
Entity Type:Organization
Organization Name:COMMUNITY PEDIATRICS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-885-3305
Mailing Address - Street 1:109 WARREN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3082
Mailing Address - Country:US
Mailing Address - Phone:920-885-3305
Mailing Address - Fax:920-885-5506
Practice Address - Street 1:109 WARREN ST STE 4
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3082
Practice Address - Country:US
Practice Address - Phone:920-885-3305
Practice Address - Fax:920-885-5506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34638800Medicaid
WI34638800Medicaid