Provider Demographics
NPI:1720035587
Name:PEDIATRIC ASSOCIATES OF WARREN
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF WARREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDOLIOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-609-5588
Mailing Address - Street 1:321 NILES CORTLAND RD NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-1974
Mailing Address - Country:US
Mailing Address - Phone:330-609-5588
Mailing Address - Fax:330-609-5740
Practice Address - Street 1:321 NILES CORTLAND RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-1974
Practice Address - Country:US
Practice Address - Phone:330-609-5588
Practice Address - Fax:330-609-5740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-1915-K208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2510812Medicaid
OH23688978Medicaid
OH0942485Medicaid