Provider Demographics
NPI:1265575955
Name:PROVIDENCE PEDIATRICS, PC
Entity type:Organization
Organization Name:PROVIDENCE PEDIATRICS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-326-5720
Mailing Address - Street 1:338 RUSSELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701
Mailing Address - Country:US
Mailing Address - Phone:570-326-5720
Mailing Address - Fax:570-601-1522
Practice Address - Street 1:338 RUSSELL AVENUE
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701
Practice Address - Country:US
Practice Address - Phone:570-326-5720
Practice Address - Fax:570-601-1522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046306L2080A0000X
PAMD046306-L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012712310004Medicaid
PA0012712310004Medicaid