1891714911 NPI number — PEDIATRIC ASSOCIATES OF PETERSBURG PLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891714911 NPI number — PEDIATRIC ASSOCIATES OF PETERSBURG PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC ASSOCIATES OF PETERSBURG PLC
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:
INFANT JESUS CHILDREN'S CLINIC
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:
1891714911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1837
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PETERSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-733-4131
Provider Business Mailing Address Fax Number:
804-862-1362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 HOLLY HILL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETERSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23805-2559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-733-4131
Provider Business Practice Location Address Fax Number:
804-862-1362
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
804-733-4131

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 13767 . This is a "SANTARA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 204646 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 529 . This is a "CARENET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1201542 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1243417 . This is a "CIGNA PPC" identifier . This identifiers is of the category "OTHER".




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