Provider Demographics
NPI:1962579151
Name:PEDIATRIC DEVELOPMENT CENTER
Entity type:Organization
Organization Name:PEDIATRIC DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ATWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-499-4537
Mailing Address - Street 1:388 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4903
Mailing Address - Country:US
Mailing Address - Phone:413-499-4537
Mailing Address - Fax:413-448-8223
Practice Address - Street 1:388 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4903
Practice Address - Country:US
Practice Address - Phone:413-499-4537
Practice Address - Fax:413-448-8223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA356074251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1800701Medicaid