Provider Demographics
NPI:1770927345
Name:PEDIATRIA HEALTHCARE, LLC
Entity type:Organization
Organization Name:PEDIATRIA HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, REGULATORY LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITESIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-248-8740
Mailing Address - Street 1:400 INTERSTATE NORTH PKWY SE STE 1600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5047
Mailing Address - Country:US
Mailing Address - Phone:770-248-8740
Mailing Address - Fax:770-248-8192
Practice Address - Street 1:1183 JACKS RUN RD
Practice Address - Street 2:
Practice Address - City:NORTH VERSAILLES
Practice Address - State:PA
Practice Address - Zip Code:15137-0000
Practice Address - Country:US
Practice Address - Phone:412-349-6708
Practice Address - Fax:412-349-6716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-25
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021992800016Medicaid