Provider Demographics
NPI:1891714911
Name:PEDIATRIC ASSOCIATES OF PETERSBURG PLC
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF PETERSBURG PLC
Other - Org Name:INFANT JESUS CHILDREN'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-733-4131
Mailing Address - Street 1:PO BOX 1837
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805
Mailing Address - Country:US
Mailing Address - Phone:804-733-4131
Mailing Address - Fax:804-862-1362
Practice Address - Street 1:5 HOLLY HILL DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2559
Practice Address - Country:US
Practice Address - Phone:804-733-4131
Practice Address - Fax:804-862-1362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
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
13767OtherSANTARA
204646OtherANTHEM
529OtherCARENET
1201542OtherUNITED HEALTH CARE
1243417OtherCIGNA PPC