Provider Demographics
NPI:1487153144
Name:PEDIATRIC CARE CENTER OF ERIE, PC
Entity type:Organization
Organization Name:PEDIATRIC CARE CENTER OF ERIE, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEKKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-454-2891
Mailing Address - Street 1:1611 PEACH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-2122
Mailing Address - Country:US
Mailing Address - Phone:814-454-2891
Mailing Address - Fax:
Practice Address - Street 1:1611 PEACH ST STE 300
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-2122
Practice Address - Country:US
Practice Address - Phone:814-454-2891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-08
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419696208000000X
PAMD038253L208000000X
PAMD440507208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1770550063Medicaid
PAMD440507OtherPA STATE LICENSE
PA1467626283Medicaid
PA1811976020Medicaid