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General NPI Number Information
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NPI Number | 1093776247
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Entity Type | Organization
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Legal Business Name | INFANTS CHILDREN AND YOUTH
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Dates
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Enumeration Date | 03/29/2006
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Last Update Date | 07/03/2008
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Provider Practice Location Address
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Address Line | 320 MIDDLETOWN BLVD THE COURTYARD SUITE 300
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City | LANGHORNE
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State | PA
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Zip | 19047-3204
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Country | US
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Telephone | 215-752-0382
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Fax | 215-752-4807
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Provider Business Mailing Address
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Address Line | 320 MIDDLETOWN BLVD THE COURTYARD SUITE 300
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City | LANGHORNE
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State | PA
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Zip | 19047-3204
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Country | US
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Telephone | 215-752-0382
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Fax | 215-752-4807
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. JERRY GREEN
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Credential | D.O.
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Telephone | 215-752-0382
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | OS004790L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD032401E
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | OS003032L
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License Number State | PA
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