Provider Demographics
NPI:1457346090
Name:PEDIATRIC ASSOICATES, INC.
Entity Type:Organization
Organization Name:PEDIATRIC ASSOICATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-501-7337
Mailing Address - Street 1:1021 COUNTRY CLUB RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2470
Mailing Address - Country:US
Mailing Address - Phone:614-501-7337
Mailing Address - Fax:614-434-2701
Practice Address - Street 1:1021 COUNTRY CLUB RD
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2470
Practice Address - Country:US
Practice Address - Phone:614-501-7337
Practice Address - Fax:614-434-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0198781Medicaid