Healthcare Provider Details

I. General information

NPI: 1184667420
Provider Name (Legal Business Name): COWPATH PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 COWPATH RD SUITE 1
LANSDALE PA
19446-1152
US

IV. Provider business mailing address

108 COWPATH RD SUITE 1
LANSDALE PA
19446-1152
US

V. Phone/Fax

Practice location:
  • Phone: 215-855-1599
  • Fax:
Mailing address:
  • Phone: 215-855-1599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS004397L
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. SUSAN DIBONO ETTINGER
Title or Position: OWNER
Credential: D.O.
Phone: 215-855-1599