Provider Demographics
NPI:1700876380
Name:CHILD HEART ASSOCIATES, LLC
Entity Type:Organization
Organization Name:CHILD HEART ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LARS
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:508-757-7300
Mailing Address - Street 1:33 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2752
Mailing Address - Country:US
Mailing Address - Phone:508-757-7300
Mailing Address - Fax:800-757-0803
Practice Address - Street 1:33 OAK AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2752
Practice Address - Country:US
Practice Address - Phone:508-757-7300
Practice Address - Fax:800-757-0803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9748661Medicaid
MA9748661Medicaid