Provider Demographics
NPI:1124136510
Name:WOBURN PEDIATRIC ASSOCIATES
Entity type:Organization
Organization Name:WOBURN PEDIATRIC ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRARCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-638-1020
Mailing Address - Street 1:7 ALFRED ST
Mailing Address - Street 2:BALDWIN PARK II
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1976
Mailing Address - Country:US
Mailing Address - Phone:781-933-6236
Mailing Address - Fax:781-938-8050
Practice Address - Street 1:7 ALFRED ST
Practice Address - Street 2:BALDWIN PARK II
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1976
Practice Address - Country:US
Practice Address - Phone:781-933-6236
Practice Address - Fax:781-938-8050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9712623Medicaid
MA25114OtherFALLON
MA805422OtherTUFTS HEALTH PLAN - LAB
MAM12470OtherBLUE CROSS BLUE SHIELD
MA600388OtherTUFTS HEALTH PLAN
MA9110OtherAETNA/US HEALTHCARE
MA9712623Medicaid