Provider Demographics
NPI:1124310586
Name:PEDIATRIC CARE SPECIALISTS
Entity type:Organization
Organization Name:PEDIATRIC CARE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:AVRAMIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-266-8840
Mailing Address - Street 1:1322 EISENHOWER BLVD
Mailing Address - Street 2:PEDIATRIC CARE SPECIALISTS
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904
Mailing Address - Country:US
Mailing Address - Phone:814-266-8840
Mailing Address - Fax:814-266-2176
Practice Address - Street 1:1322 EISENHOWER BLVD
Practice Address - Street 2:PEDIATRIC CARE SPECIALISTS
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904
Practice Address - Country:US
Practice Address - Phone:814-266-8840
Practice Address - Fax:814-266-2176
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC CARE SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW015802104100000X
PAPS016634103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007708200003Medicaid