MEDICARE: PENNSYLVANIA PET ASSOCIATES 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	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1710966080
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENNSYLVANIA PET ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	43 LEOPARD RD
Second Line	:	SUITE 200
City	:	PAOLI
State	:	PA
Zip	:	19301-1552
Country	:	US
Telephone Number	:	610-993-1640
Fax Number	:	610-993-1651

Provider Business Practice Location Address
First Line	:	800 SPRUCE ST
Second Line	:	SECOND FLOOR, WIDENER BUILDING
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-6130
Country	:	US
Telephone Number	:	215-829-6554
Fax Number	:	215-829-6552

Authorized Official
Title or Position	:	DIRECTOR OF INSTITUTIONAL RELATIONS
Name	:	MR. EDWARD J GRACE
Credential	:
Telephone Number	:	610-993-1640

Provider Enumeration Date	:	01/13/2006
Last Update Date	:	06/18/2008

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