Healthcare Provider Details

I. General information

NPI: 1033287552
Provider Name (Legal Business Name): ALL STAR PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 GORDON DR
EXTON PA
19341-1253
US

IV. Provider business mailing address

702 GORDON DR
EXTON PA
19341-1253
US

V. Phone/Fax

Practice location:
  • Phone: 610-363-1330
  • Fax:
Mailing address:
  • Phone: 610-363-1330
  • Fax:

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:

# 1
Identifier0011937443002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: DR. BRADLEY J. DYER
Title or Position: PRESIDENT
Credential: MD
Phone: 610-363-1330