Healthcare Provider Details

I. General information

NPI: 1164534731
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4735 OGLETOWN STANTON RD MAP 2 SUITE 1116
NEWARK DE
19713-2072
US

IV. Provider business mailing address

4735 OGLETOWN STANTON RD MAP 2 SUITE 1116
NEWARK DE
19713-2072
US

V. Phone/Fax

Practice location:
  • Phone: 302-368-8612
  • Fax: 302-368-8836
Mailing address:
  • Phone: 302-368-8612
  • Fax: 302-368-8836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1989014003
License Number StateDE

VIII. Authorized Official

Name: MR. MELISSA L MACOLLEY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 302-368-8612