Healthcare Provider Details

I. General information

NPI: 1528178787
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF CHARLOTTESVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 E JEFFERSON ST
CHARLOTTESVILLE VA
22902-5354
US

IV. Provider business mailing address

1011 E JEFFERSON ST
CHARLOTTESVILLE VA
22902-5354
US

V. Phone/Fax

Practice location:
  • Phone: 434-296-9161
  • Fax: 434-296-1036
Mailing address:
  • Phone: 434-296-9161
  • Fax: 434-296-1036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. PAUL WISMAN JR.
Title or Position: PHYSICIAN
Credential:
Phone: 434-296-9161