Healthcare Provider Details

I. General information

NPI: 1275749566
Provider Name (Legal Business Name): COMMUNITY PEDIATRICS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 WARREN ST STE 4
BEAVER DAM WI
53916-3082
US

IV. Provider business mailing address

109 WARREN ST STE 4
BEAVER DAM WI
53916-3082
US

V. Phone/Fax

Practice location:
  • Phone: 920-885-3305
  • Fax: 920-885-5506
Mailing address:
  • Phone: 920-885-3305
  • Fax: 920-885-5506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. DOROTHY JEAN LARSON
Title or Position: ACCOUNT MANAGER
Credential:
Phone: 920-885-3305