MEDICARE: CHILDEN'S COMMUNITY CARE

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

General Provider Information

NPI Number	:	1275135873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDEN'S COMMUNITY CARE

Provider Business Mailing Address
First Line	:	103 BRADFORD RD STE 200
Second Line	:
City	:	WEXFORD
State	:	PA
Zip	:	15090-6910
Country	:	US
Telephone Number	:	724-933-1100
Fax Number	:	724-933-1160

Provider Business Practice Location Address
First Line	:	22 ROTH CHURCH RD
Second Line	:
City	:	SPRING GROVE
State	:	PA
Zip	:	17362-1406
Country	:	US
Telephone Number	:	717-757-3400
Fax Number	:	717-757-3702

Authorized Official
Title or Position	:	EXECUTIVE ADMINISTRATOR III
Name	:	LORI MARTINEZ
Credential	:
Telephone Number	:	724-933-1100

Provider Enumeration Date	:	11/10/2020
Last Update Date	:	09/13/2023

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