=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033750047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESTAGES PEDIATRICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2019
-----------------------------------------------------
Last Update Date | 10/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8080 OLD YORK RD STE 207
-----------------------------------------------------
City | ELKINS PARK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19027-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-935-6493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8080 OLD YORK RD STE 207
-----------------------------------------------------
City | ELKINS PARK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19027-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-935-6493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/PHYSICIAN
-----------------------------------------------------
Name | DR. ANNIE KOTTO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 215-935-6493
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------