Provider Demographics
NPI:1336212422
Name:CENTRE PEDIATRIC ASSOCIATES PC
Entity type:Organization
Organization Name:CENTRE PEDIATRIC ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:WILLARD
Authorized Official - Last Name:BUNNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-735-8585
Mailing Address - Street 1:1 BROOKLINE PL
Mailing Address - Street 2:SUITE 327
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7224
Mailing Address - Country:US
Mailing Address - Phone:617-735-8585
Mailing Address - Fax:617-232-0572
Practice Address - Street 1:1 BROOKLINE PL
Practice Address - Street 2:SUITE 327
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7224
Practice Address - Country:US
Practice Address - Phone:617-735-8585
Practice Address - Fax:617-232-0572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA92057OtherAETNA USHEALTHCARE
MA9767312Medicaid
MA711716OtherTUFTS
MAM14606OtherBLUE CROSS BLUE SHIELD