Provider Demographics
NPI:1295920015
Name:PEDIATRIC ASSOCIATES, LLC
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:I
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-589-5238
Mailing Address - Street 1:10 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-8102
Mailing Address - Country:US
Mailing Address - Phone:860-589-5230
Mailing Address - Fax:860-589-5297
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-8102
Practice Address - Country:US
Practice Address - Phone:860-589-5230
Practice Address - Fax:860-589-5297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1896539000261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care