Provider Demographics
NPI:1053612911
Name:MANCHESTER PEDIATRIC ASSOCIATES LLC
Entity type:Organization
Organization Name:MANCHESTER PEDIATRIC ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SWATHANTHRA
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:MELEKOTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-647-8282
Mailing Address - Street 1:2701 TAMARACK AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-5561
Mailing Address - Country:US
Mailing Address - Phone:860-647-8282
Mailing Address - Fax:860-647-8399
Practice Address - Street 1:2701 TAMARACK AVE
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5561
Practice Address - Country:US
Practice Address - Phone:860-647-8282
Practice Address - Fax:860-647-8399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043564208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1629061965Medicaid
CTI41682Medicare UPIN