Healthcare Provider Details

I. General information

NPI: 1992800940
Provider Name (Legal Business Name): MEMPHIS STREET PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3380 MEMPHIS ST
PHILADELPHIA PA
19134-4510
US

IV. Provider business mailing address

3380 MEMPHIS ST
PHILADELPHIA PA
19134-4510
US

V. Phone/Fax

Practice location:
  • Phone: 215-426-5566
  • Fax: 215-739-7304
Mailing address:
  • Phone: 215-426-5566
  • Fax: 215-739-7304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LOUISE T HOLMES
Title or Position: PRACTICE MANAGER
Credential:
Phone: 215-707-1059