Provider Demographics
NPI:1124150347
Name:CHILDREN'S GARDEN PEDIATRICS, LLC
Entity type:Organization
Organization Name:CHILDREN'S GARDEN PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:EILEEN
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-441-9276
Mailing Address - Street 1:799 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1048
Mailing Address - Country:US
Mailing Address - Phone:617-441-9276
Mailing Address - Fax:617-491-5222
Practice Address - Street 1:799 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1048
Practice Address - Country:US
Practice Address - Phone:617-441-9276
Practice Address - Fax:617-491-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213874208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA644754OtherTUFTS GROUP NUMBER
MA9746030Medicaid
MAM19222OtherBCBS GROUP NUMBER