Healthcare Provider Details

I. General information

NPI: 1013081223
Provider Name (Legal Business Name): PEDIATRIC HEALTHCARE ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 EAST CHARLES STREET
LAPLATA MA
20646
US

IV. Provider business mailing address

4815 GRANDVIEW PLACE
LAPLATA MA
20646-2846
US

V. Phone/Fax

Practice location:
  • Phone: 301-751-6058
  • Fax: 301-392-0892
Mailing address:
  • Phone: 301-753-1918
  • Fax: 301-392-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: TOLLESE BANKETT
Title or Position: PRESIDENT
Credential: MD
Phone: 301-753-1918