Provider Demographics
NPI:1649441205
Name:PEDIATRIA HEALTHCARE, LLC
Entity type:Organization
Organization Name:PEDIATRIA HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:DIGNAN
Authorized Official - Suffix:
Authorized Official - Credentials:ATTORNEY
Authorized Official - Phone:770-840-1966
Mailing Address - Street 1:5185 PEACHTREE PKWY
Mailing Address - Street 2:STE 350
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-6542
Mailing Address - Country:US
Mailing Address - Phone:770-840-1966
Mailing Address - Fax:770-840-1901
Practice Address - Street 1:8101 WASHINGTON LN
Practice Address - Street 2:SUITE 250
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095-1625
Practice Address - Country:US
Practice Address - Phone:215-376-6516
Practice Address - Fax:215-376-6520
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIA HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-21
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA3310501251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102199280 0003Medicaid
PA102199280 0003Medicaid