Provider Demographics
NPI:1033220108
Name:PEDIATRICS AND ADOLESCENT MEDICINE, P.C.
Entity type:Organization
Organization Name:PEDIATRICS AND ADOLESCENT MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-795-4924
Mailing Address - Street 1:240 INDIAN RIVER RD
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-3649
Mailing Address - Country:US
Mailing Address - Phone:203-795-4924
Mailing Address - Fax:203-799-1554
Practice Address - Street 1:240 INDIAN RIVER RD
Practice Address - Street 2:SUITE B-1
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3649
Practice Address - Country:US
Practice Address - Phone:203-795-4924
Practice Address - Fax:203-799-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4394003Medicaid