Provider Demographics
NPI:1437210325
Name:WELLSBORO PEDIATRIC HEALTH CARE ASSOCIATES
Entity Type:Organization
Organization Name:WELLSBORO PEDIATRIC HEALTH CARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-724-7100
Mailing Address - Street 1:1B MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1601
Mailing Address - Country:US
Mailing Address - Phone:570-724-7100
Mailing Address - Fax:570-724-1501
Practice Address - Street 1:1B MAIN STREET
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1601
Practice Address - Country:US
Practice Address - Phone:570-724-7100
Practice Address - Fax:570-724-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029130E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4623938OtherAETNA
006529900OtherPERSONAL CHOICE
34219OtherUPMC
2603062OtherGHI
CX28OtherHEALTH ASSURANCE
794397OtherHEALTH CARE ADVANTAGE
PA0606293OtherACCESS CARE II
PA070598OtherBLUE SHIELD
NY01032526Medicaid
PA39D0980728OtherCLEA
PA0009089200001Medicaid
002502OtherFIRST PRIORITY
NY050466997OtherBLUE SHIELD
13037OtherGHP
NY01032526Medicaid