Provider Demographics
NPI:1134563711
Name:PEDIATRIA HEALTHCARE, LLC
Entity type:Organization
Organization Name:PEDIATRIA HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, CHAIRMAN & MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:SANSONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-840-1966
Mailing Address - Street 1:5185 PEACHTREE PKWY
Mailing Address - Street 2:SUITE 350
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-6542
Mailing Address - Country:US
Mailing Address - Phone:770-840-1966
Mailing Address - Fax:770-840-1901
Practice Address - Street 1:1185 JACKS RUN RD
Practice Address - Street 2:S.R. 48
Practice Address - City:NORTH VERSAILLES
Practice Address - State:PA
Practice Address - Zip Code:15137-2725
Practice Address - Country:US
Practice Address - Phone:412-349-6712
Practice Address - Fax:412-349-6717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-25
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05250501251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021992800017Medicaid
PA398157Medicare Oscar/Certification