Provider Demographics
NPI:1831386317
Name:PEDIATRIC PRACTICE ASSOCIATES, P.C.
Entity type:Organization
Organization Name:PEDIATRIC PRACTICE ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAYDEE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LANCMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-323-8171
Mailing Address - Street 1:1515 SUMMER ST
Mailing Address - Street 2:STE. 101
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5149
Mailing Address - Country:US
Mailing Address - Phone:203-323-8171
Mailing Address - Fax:203-323-7122
Practice Address - Street 1:1515 SUMMER ST
Practice Address - Street 2:STE. 101
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5149
Practice Address - Country:US
Practice Address - Phone:203-323-8171
Practice Address - Fax:203-323-7122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037157208000000X, 2080A0000X
CT003351363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty