Healthcare Provider Details

I. General information

NPI: 1649441205
Provider Name (Legal Business Name): PEDIATRIA HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2008
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 WASHINGTON LN SUITE 250
WYNCOTE PA
19095-1625
US

IV. Provider business mailing address

5185 PEACHTREE PKWY STE 350
NORCROSS GA
30092-6542
US

V. Phone/Fax

Practice location:
  • Phone: 215-376-6516
  • Fax: 215-376-6520
Mailing address:
  • Phone: 770-840-1966
  • Fax: 770-840-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number3310501
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier102199280 0003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MS. SUSAN ELIZABETH DIGNAN
Title or Position: GENERAL COUNSEL
Credential: ATTORNEY
Phone: 770-840-1966