MEDICARE: CHILDREN'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	207N00000X	Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001633210	OTHER	PA	HIGHMARK

General Provider Information

NPI Number	:	1619058559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'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	:	11279 PERRY HWY STE 108
Second Line	:
City	:	WEXFORD
State	:	PA
Zip	:	15090-9303
Country	:	US
Telephone Number	:	724-933-9190
Fax Number	:	724-933-9194

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

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	09/13/2023

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Directions to “CHILDREN'S COMMUNITY CARE ” Practice Location

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