Healthcare Provider Details

I. General information

NPI: 1356443543
Provider Name (Legal Business Name): THE PEDIATRIC & ADOLESCENT MEDICINE CENTERS OF PHILADELPHIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W SCHOOLHOUSE LANE
PHILADELPHIA PA
19144
US

IV. Provider business mailing address

105 W SCHOOLHOUSE LANE
PHILADELPHIA PA
19144
US

V. Phone/Fax

Practice location:
  • Phone: 215-848-9000
  • Fax: 215-848-7894
Mailing address:
  • Phone: 215-848-9000
  • Fax: 215-848-7894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD032197E
License Number StatePA

VIII. Authorized Official

Name: PAMELA HUFFMAN-DEVAUGHN
Title or Position: PHYSICIAN CEO
Credential: MD
Phone: 215-848-9000