MEDICARE: SUGARTOWN PEDIATRICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	MD425790	PA

General Provider Information

NPI Number	:	1093082463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUGARTOWN PEDIATRICS, LLC

Provider Business Mailing Address
First Line	:	1242 HIGHGATE RD
Second Line	:
City	:	WEST CHESTER
State	:	PA
Zip	:	19380-5846
Country	:	US
Telephone Number	:	484-266-9103
Fax Number	:	610-540-0156

Provider Business Practice Location Address
First Line	:	4875 W CHESTER PIKE
Second Line	:
City	:	NEWTOWN SQUARE
State	:	PA
Zip	:	19073-2213
Country	:	US
Telephone Number	:	484-206-5500
Fax Number	:	484-206-5505

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	LOUIS M GIANGIULIO
Credential	:	M.D.
Telephone Number	:	484-266-9103

Provider Enumeration Date	:	11/29/2011
Last Update Date	:	11/29/2011

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