Provider Demographics
NPI:1144318791
Name:GLOUCESTER PEDIATRICS, PC
Entity type:Organization
Organization Name:GLOUCESTER PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:ALLISON-BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-694-0011
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:7574 HOSPITAL DR.
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-0700
Mailing Address - Country:US
Mailing Address - Phone:804-694-0011
Mailing Address - Fax:804-693-0355
Practice Address - Street 1:7574 HOSPITAL DR.
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-0700
Practice Address - Country:US
Practice Address - Phone:804-694-0011
Practice Address - Fax:804-693-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA095240OtherANTHEM BCBS