Healthcare Provider Details

I. General information

NPI: 1497788327
Provider Name (Legal Business Name): PANDA BEAR PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 SOUTH SECOND AVENUE BUILDING B, SUITE 200
COLLEGEVILLE PA
19426-2854
US

IV. Provider business mailing address

102 SHETLAND WAY
COLLEGEVILLE PA
19426-2854
US

V. Phone/Fax

Practice location:
  • Phone: 610-409-8050
  • Fax: 610-409-8075
Mailing address:
  • Phone: 610-409-8050
  • Fax: 610-409-8075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS-009162L
License Number StatePA

VIII. Authorized Official

Name: DR. LARISSA F DOMINY
Title or Position: PHYSICIAN/MANAGING MEMBER
Credential: D.O.
Phone: 610-409-8050