Provider Demographics
NPI:1134189889
Name:PEDIATRIC HOUSE CALL PC
Entity type:Organization
Organization Name:PEDIATRIC HOUSE CALL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:STAVITSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-916-5085
Mailing Address - Street 1:56 WINCHESTER ST STE 5
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1730
Mailing Address - Country:US
Mailing Address - Phone:617-916-5085
Mailing Address - Fax:617-916-5105
Practice Address - Street 1:56 WINCHESTER ST STE 5
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02461-1730
Practice Address - Country:US
Practice Address - Phone:617-916-5085
Practice Address - Fax:617-916-5105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-26
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77664174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3154882Medicaid
MAA292941Medicaid
MA3154882Medicaid
MAG32424Medicare UPIN
MAA292941Medicaid