Provider Demographics
NPI:1548261324
Name:PEDIATRIC ASSOCIATES PROF LLC
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES PROF LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:DAWSON
Authorized Official - Last Name:WIARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-249-2421
Mailing Address - Street 1:947 SO 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5716
Mailing Address - Country:US
Mailing Address - Phone:970-249-2421
Mailing Address - Fax:970-249-8897
Practice Address - Street 1:947 SO 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5716
Practice Address - Country:US
Practice Address - Phone:970-249-2421
Practice Address - Fax:970-249-8897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25232339Medicaid
COTHF8408OtherBLUE CROSS/BLUE SHIELD