Healthcare Provider Details

I. General information

NPI: 1760588552
Provider Name (Legal Business Name): PENNSBORO PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N ENOLA DR STE 101
ENOLA PA
17025-2500
US

IV. Provider business mailing address

125 N ENOLA DR STE 101
ENOLA PA
17025-2500
US

V. Phone/Fax

Practice location:
  • Phone: 717-732-7171
  • Fax: 717-732-8872
Mailing address:
  • Phone: 717-732-7171
  • Fax: 717-732-8872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. RICHARD BLUTSTEIN
Title or Position: MANAGER
Credential: MD
Phone: 717-732-7171