Provider Demographics
NPI:1275841488
Name:YOUTHCARE PEDIATRICS
Entity Type:Organization
Organization Name:YOUTHCARE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MITORAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-968-4007
Mailing Address - Street 1:212 MIDWAY MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1664
Mailing Address - Country:US
Mailing Address - Phone:423-968-4007
Mailing Address - Fax:423-652-2590
Practice Address - Street 1:212 MIDWAY MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1664
Practice Address - Country:US
Practice Address - Phone:423-968-4007
Practice Address - Fax:423-652-2590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN021345208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3060577Medicaid
TN0123498OtherBLUE CROSS TN
VA042029OtherANTHEM
VA006746080Medicaid
F21037Medicare UPIN