Healthcare Provider Details

I. General information

NPI: 1952581928
Provider Name (Legal Business Name): PEDICORP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 N MAIN ST SUITE 248
WEST HARTFORD CT
06117-2515
US

IV. Provider business mailing address

345 N MAIN ST SUITE 248
WEST HARTFORD CT
06117-2515
US

V. Phone/Fax

Practice location:
  • Phone: 860-231-8453
  • Fax: 860-523-4061
Mailing address:
  • Phone: 860-231-8453
  • Fax: 860-523-4061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. ELLEN GUERTIN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 860-231-8453