Provider Demographics
NPI:1457571754
Name:PEDIATRIC ASSOC OF PETERSBURG
Entity type:Organization
Organization Name:PEDIATRIC ASSOC OF PETERSBURG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-530-7413
Mailing Address - Street 1:13213 RIVERS BEND BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-8606
Mailing Address - Country:US
Mailing Address - Phone:804-530-7413
Mailing Address - Fax:804-530-7411
Practice Address - Street 1:13213 RIVERS BEND BLVD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23836-8606
Practice Address - Country:US
Practice Address - Phone:804-530-7413
Practice Address - Fax:804-530-7411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101026123208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134065OtherOPTIMUM CHOICE DR TAMARA
VA13767OtherOPTIMA HEALTH MEDICAID HM
213114OtherOPTIMUM CHOICE DR HERMES
2134065OtherALLIANCE PPO DR TAMARA CH
4365024OtherAETNA DRPATRICIA GONZALES
6657468OtherCIGNA DR TAMARA CHARITY B
6674705OtherCIGNA DR HERMES DIZON
1243417OtherCIGNA DRPATRICIA GONZALES
266582OtherSOUTHERN HEALTH DR PATRIC
2134065OtherMDIPA DR TAMARA CHARITY B
23468OtherSENTARA OPTIMA HEALTH DR
1201542OtherUNITED HEALTHCARE DR PATR
VA466594OtherANTHEM BLUE CROSS
13767OtherSENTARA OPTIMA HEALTH DR
306087OtherSOUTHERN HEALTH DR HERMES
2100405OtherMAMSI DR PATRICIA GONZALE
213114OtherMDIPA DR HERMES DIZON
5293OtherCARENET DR PATRICIA GONZA
002478499004OtherUNITED HEALTHCARE DR HERM
57968OtherCARENET DR TAMARA CHARITY