Healthcare Provider Details

I. General information

NPI: 1760932099
Provider Name (Legal Business Name): CHILDRENS COMMUNITY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4075 MONROEVILLE BLVD STE 125
MONROEVILLE PA
15146-2526
US

IV. Provider business mailing address

103 BRADFORD RD STE 200
WEXFORD PA
15090-6910
US

V. Phone/Fax

Practice location:
  • Phone: 724-933-9190
  • Fax: 724-933-9194
Mailing address:
  • Phone: 724-933-1100
  • Fax: 724-933-1160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: LORI MARTINEZ
Title or Position: EXECUTIVE ADMINISTRATOR III
Credential:
Phone: 724-933-1100