Healthcare Provider Details

I. General information

NPI: 1255151601
Provider Name (Legal Business Name): PLYMOUTH PEDIATRIC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 INDUSTRIAL PARK RD
PLYMOUTH MA
02360-7243
US

IV. Provider business mailing address

148 INDUSTRIAL PARK RD
PLYMOUTH MA
02360-7243
US

V. Phone/Fax

Practice location:
  • Phone: 508-503-2646
  • Fax:
Mailing address:
  • Phone: 508-503-2646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHRIS CLODI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 508-503-2646