Healthcare Provider Details

I. General information

NPI: 1740654599
Provider Name (Legal Business Name): WORCESTER PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2015
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SUMMER ST 690 NORTH
WORCESTER MA
01608-1216
US

IV. Provider business mailing address

123 SUMMER ST 690 NORTH
WORCESTER MA
01608-1216
US

V. Phone/Fax

Practice location:
  • Phone: 508-363-9530
  • Fax: 508-363-9535
Mailing address:
  • Phone: 508-363-9530
  • Fax: 508-363-9535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PAULETTE KIMBALL-WREN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 508-363-9530