MEDICARE: PEDIATRIC CARE CENTER OF ERIE, PC

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	MD419696	PA
2	208000000X	Pediatrics Physician	MD038253L	PA
3	208000000X	Pediatrics Physician	MD440507	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MD440507	OTHER	PA	PA STATE LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487153144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC CARE CENTER OF ERIE, PC

Provider Business Mailing Address
First Line	:	1611 PEACH ST STE 300
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16501-2122
Country	:	US
Telephone Number	:	814-454-2891
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 PEACH ST STE 300
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16501-2122
Country	:	US
Telephone Number	:	814-454-2891
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RAVI CHEKKA
Credential	:	MD
Telephone Number	:	814-454-2891

Provider Enumeration Date	:	02/08/2018
Last Update Date	:	10/01/2020

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