Healthcare Provider Details

I. General information

NPI: 1972691103
Provider Name (Legal Business Name): PEDIATRIC CARE CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NEALE ADDRESS MAHONING MEDICAL CENTER
MARION CENTER PA
15759-0268
US

IV. Provider business mailing address

ROUTE 403 SOUTH PO BOX 268
MARION CENTER PA
15759
US

V. Phone/Fax

Practice location:
  • Phone: 724-397-2326
  • Fax:
Mailing address:
  • Phone: 724-397-2326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier613096
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerPA BLUE SHIELD

VIII. Authorized Official

Name: RIZWAN JABIR
Title or Position: OWNER
Credential: M.D.
Phone: 724-397-2326