NPIMap

Organization Active NPI

The Pediatric Care Center, LLC

  • Pediatrics Physician
  • Bristol, CT
National Provider Identifier
1902357163
Registry record updated Oct 7, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
License
038949 Issued in CT
Legal business name
THE PEDIATRIC CARE CENTER, LLC
Practice address
1301 Farmington Ave
Bristol, CT 06010-4776
Phone
(860) 589-4501
Fax
(860) 589-4502
NPI assigned
Oct 21, 2016
Last updated
Oct 7, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 7, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Susan Adeyinka, MD
Title
Owner
Phone
(860) 589-4501

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X 038949 CT Primary

Addresses

Primary practice location

1301 Farmington Ave
Bristol, CT 06010-4776

Mailing address

1301 Farmington Ave
Bristol, CT 06010-4776
Phone (860) 589-4501

Other identifiers 1

IdentifierTypeStateIssuer
1389495MedicaidCT

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
07D1076562Pediatric Care Center, LLC,the1301 Farmington Avenue, Bristol, CT 06010Certificate of waiverNov 15, 2027

National Provider Directory

National Provider Directory
Tax ID family
The Pediatric Care Center2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1477008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1602028800000",
    "number": "1902357163",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1301 FARMINGTON AVE",
            "city": "BRISTOL",
            "state": "CT",
            "postal_code": "060104776",
            "telephone_number": "860-589-4501",
            "fax_number": "860-589-4502"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1301 FARMINGTON AVE",
            "city": "BRISTOL",
            "state": "CT",
            "postal_code": "060104776",
            "telephone_number": "860-589-4501",
            "fax_number": "860-589-4502"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE PEDIATRIC CARE CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-10-21",
        "last_updated": "2020-10-07",
        "certification_date": "2020-10-07",
        "status": "A",
        "authorized_official_last_name": "ADEYINKA",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "860-589-4501",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "CT",
            "license": "038949",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1389495",
            "state": "CT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Bristol, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 7, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.