Provider Demographics
NPI:1952427072
Name:THE PEDIATRIC CENTER OF FREDERICK, LLC
Entity Type:Organization
Organization Name:THE PEDIATRIC CENTER OF FREDERICK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:VANPELT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-631-8053
Mailing Address - Street 1:1475 TANEY AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4747
Mailing Address - Country:US
Mailing Address - Phone:301-631-8053
Mailing Address - Fax:301-695-8604
Practice Address - Street 1:1475 TANEY AVE
Practice Address - Street 2:STE 201
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4747
Practice Address - Country:US
Practice Address - Phone:301-631-8053
Practice Address - Fax:301-695-8604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218841400Medicaid