Provider Demographics
NPI:1497960215
Name:SANDWICH PEDIATRICS
Entity Type:Organization
Organization Name:SANDWICH PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:SARAH
Authorized Official - Last Name:KOENIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-888-8430
Mailing Address - Street 1:449 ROUTE 130
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02563-2339
Mailing Address - Country:US
Mailing Address - Phone:508-888-8430
Mailing Address - Fax:508-888-6673
Practice Address - Street 1:449 ROUTE 130
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:MA
Practice Address - Zip Code:02563-2339
Practice Address - Country:US
Practice Address - Phone:508-888-8430
Practice Address - Fax:508-888-6673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA500012080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9766006Medicaid
MASAM15113OtherBLUE CROSS BLUE SHIELD
MAE43453Medicare UPIN