1619154747 NPI number — THE PEDIATRIC CONNECTION, INC.

Table of content: (NPI 1619154747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619154747 NPI number — THE PEDIATRIC CONNECTION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PEDIATRIC CONNECTION, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THRIVE SKILLED PEDIATRIC CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619154747
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 EDGEWATER DRIVE, SUITE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAKEFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01880-1262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-486-4100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 N CENTRAL AVE STE 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAUNTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24401-4212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-675-4550
Provider Business Practice Location Address Fax Number:
434-227-5703
Provider Enumeration Date:
01/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
MELINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
781-486-4100

Provider Taxonomy Codes

  • Taxonomy code: 163WP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X , with the licence number: 0206009102 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30015177800007 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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