Provider Demographics
NPI:1811453020
Name:PEDIATRIC CARE OF ROCKVILLE PA
Entity type:Organization
Organization Name:PEDIATRIC CARE OF ROCKVILLE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-881-7995
Mailing Address - Street 1:1201 SEVEN LOCKS RD STE 201
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2963
Mailing Address - Country:US
Mailing Address - Phone:301-881-7995
Mailing Address - Fax:301-881-8451
Practice Address - Street 1:1201 SEVEN LOCKS RD STE 201
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20854-2963
Practice Address - Country:US
Practice Address - Phone:301-881-7995
Practice Address - Fax:301-881-8451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-12
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD147151101Medicaid
MD147151100Medicaid