Provider Demographics
NPI:1508370701
Name:PEDS CENTER OF ROUND ROCK PA
Entity Type:Organization
Organization Name:PEDS CENTER OF ROUND ROCK PA
Other - Org Name:RIVER RIDGE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIVEKANANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DASARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-289-7621
Mailing Address - Street 1:1526 LEANDER RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-8801
Mailing Address - Country:US
Mailing Address - Phone:512-863-7586
Mailing Address - Fax:512-863-5222
Practice Address - Street 1:1526 LEANDER RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-8801
Practice Address - Country:US
Practice Address - Phone:512-863-7586
Practice Address - Fax:512-863-5222
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDS CENTER OF ROUND ROCK PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty