Provider Demographics
NPI:1902292899
Name:UNIVERSITY PEDIATRICS DBA CHILDREN'S MEDICAL GROUP
Entity Type:Organization
Organization Name:UNIVERSITY PEDIATRICS DBA CHILDREN'S MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:III
Authorized Official - Credentials:PPCNP-BC
Authorized Official - Phone:401-633-1100
Mailing Address - Street 1:100 HIGHLAND AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2740
Mailing Address - Country:US
Mailing Address - Phone:401-633-1100
Mailing Address - Fax:401-633-0047
Practice Address - Street 1:100 HIGHLAND AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2740
Practice Address - Country:US
Practice Address - Phone:401-633-1100
Practice Address - Fax:401-633-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN00401363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty