Provider Demographics
NPI:1710028188
Name:PEDIATRIC ASSOCIATES OF WELLESLEY
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF WELLESLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DALE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-736-0040
Mailing Address - Street 1:134 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-1923
Mailing Address - Country:US
Mailing Address - Phone:781-736-0040
Mailing Address - Fax:781-736-7929
Practice Address - Street 1:134 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:MA
Practice Address - Zip Code:02493-1923
Practice Address - Country:US
Practice Address - Phone:781-736-0040
Practice Address - Fax:781-736-7929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM15807OtherBLUE CROSS OF MASS
MA713364OtherTUFTS HEALTH PLAN
MA9759204Medicaid
MA=========OtherHARVARD PILGRIM HEALTH PL