Provider Demographics
NPI:1356341770
Name:THE CHILDRENS CLININIC OF WYOMISSING
Entity type:Organization
Organization Name:THE CHILDRENS CLININIC OF WYOMISSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:B
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-376-8698
Mailing Address - Street 1:2240 RIDGEWOOD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1167
Mailing Address - Country:US
Mailing Address - Phone:610-378-1722
Mailing Address - Fax:610-376-8745
Practice Address - Street 1:2240 RIDGEWOOD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1167
Practice Address - Country:US
Practice Address - Phone:610-378-1722
Practice Address - Fax:610-376-8745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041246E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007022820002Medicaid