Provider Demographics
NPI:1760487854
Name:PEDIATRIC CENTER, PC
Entity Type:Organization
Organization Name:PEDIATRIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-363-3600
Mailing Address - Street 1:411 10TH STREET SE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403
Mailing Address - Country:US
Mailing Address - Phone:319-363-3600
Mailing Address - Fax:319-363-9971
Practice Address - Street 1:411 10TH STREET SE
Practice Address - Street 2:SUITE 150
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403
Practice Address - Country:US
Practice Address - Phone:319-363-3600
Practice Address - Fax:319-363-9971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0137885Medicaid
IA2016428Medicaid
IA1053173Medicaid
IA1088492Medicaid
IA0171215Medicaid
IAB68881Medicare UPIN
IAG31853Medicare UPIN
IAD89674Medicare UPIN
IA1053173Medicaid
IA2016428Medicaid
IA1088492Medicaid
IA0137885Medicaid