Healthcare Provider Details

I. General information

NPI: 1265575955
Provider Name (Legal Business Name): PROVIDENCE PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 RUSSELL AVENUE
WILLIAMSPORT PA
17701
US

IV. Provider business mailing address

338 RUSSELL AVENUE
WILLIAMSPORT PA
17701
US

V. Phone/Fax

Practice location:
  • Phone: 570-326-5720
  • Fax: 570-601-1522
Mailing address:
  • Phone: 570-326-5720
  • Fax: 570-601-1522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD046306-L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD046306L
License Number StatePA

VIII. Authorized Official

Name: DR. JOSEPH DEMAY
Title or Position: PRESIDENT
Credential: MD
Phone: 570-326-5720