Provider Demographics
NPI:1912120916
Name:BRIGHT OAKS PEDIATRIC CENTER, LLC
Entity Type:Organization
Organization Name:BRIGHT OAKS PEDIATRIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WUNDERER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-569-3300
Mailing Address - Street 1:2111 LAUREL BUSH RD STE H
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-6156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2111 LAUREL BUSH RD STE H
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-6156
Practice Address - Country:US
Practice Address - Phone:410-569-3300
Practice Address - Fax:410-515-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0045592208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty