Provider Demographics
NPI:1952581928
Name:PEDICORP, PC
Entity type:Organization
Organization Name:PEDICORP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUERTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-231-8453
Mailing Address - Street 1:345 N MAIN ST
Mailing Address - Street 2:SUITE 248
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2515
Mailing Address - Country:US
Mailing Address - Phone:860-231-8453
Mailing Address - Fax:860-523-4061
Practice Address - Street 1:345 N MAIN ST
Practice Address - Street 2:SUITE 248
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2515
Practice Address - Country:US
Practice Address - Phone:860-231-8453
Practice Address - Fax:860-523-4061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty