Provider Demographics
NPI:1780710640
Name:PEDIATRICS AT NEWTON WELLESLEY, PC
Entity type:Organization
Organization Name:PEDIATRICS AT NEWTON WELLESLEY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDEOUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-969-8989
Mailing Address - Street 1:2000 WASHINGTON ST
Mailing Address - Street 2:SUITE #466
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1650
Mailing Address - Country:US
Mailing Address - Phone:617-969-8989
Mailing Address - Fax:617-928-0178
Practice Address - Street 1:2000 WASHINGTON ST
Practice Address - Street 2:SUITE #466
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1650
Practice Address - Country:US
Practice Address - Phone:617-969-8989
Practice Address - Fax:617-928-0178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty