Provider Demographics
NPI:1962553917
Name:PEDIATRIC SERVICES PA
Entity type:Organization
Organization Name:PEDIATRIC SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ZERBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-922-4200
Mailing Address - Street 1:4700 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5701
Mailing Address - Country:US
Mailing Address - Phone:952-922-4200
Mailing Address - Fax:952-922-4301
Practice Address - Street 1:4700 PARK GLEN RD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-5701
Practice Address - Country:US
Practice Address - Phone:952-922-4200
Practice Address - Fax:952-922-4301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1056261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN485010600Medicaid