MEDICARE: PEDIATRIC ASSOCIATES, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	1989014003	DE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	75682001	OTHER	DE	AMERIHEALTH GROUP
2	78530	OTHER	DE	AETNA GROUP
3	0075682000	OTHER	DE	IBC GROUP
4	0000079002	OTHER	DE	IBC GROUP

General Provider Information

NPI Number	:	1164534731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC ASSOCIATES, PA

Provider Business Mailing Address
First Line	:	4735 OGLETOWN STANTON RD
Second Line	:	MAP 2 SUITE 1116
City	:	NEWARK
State	:	DE
Zip	:	19713-2072
Country	:	US
Telephone Number	:	302-368-8612
Fax Number	:	302-368-8836

Provider Business Practice Location Address
First Line	:	4735 OGLETOWN STANTON RD
Second Line	:	MAP 2 SUITE 1116
City	:	NEWARK
State	:	DE
Zip	:	19713-2072
Country	:	US
Telephone Number	:	302-368-8612
Fax Number	:	302-368-8836

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MR. MELISSA L MACOLLEY
Credential	:
Telephone Number	:	302-368-8612

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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