Provider Demographics
NPI:1477822690
Name:THE PEDIATRIC CENTER
Entity Type:Organization
Organization Name:THE PEDIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-327-1055
Mailing Address - Street 1:126 MORGAN STREET
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:09605
Mailing Address - Country:US
Mailing Address - Phone:203-327-1055
Mailing Address - Fax:203-323-6177
Practice Address - Street 1:126 MORGAN STREET
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:09605
Practice Address - Country:US
Practice Address - Phone:203-327-1055
Practice Address - Fax:203-323-6177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001946163WP0200X
CT001903363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0200XNursing Service ProvidersRegistered NursePediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004129781Medicaid