=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447311576
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC & PREVENTIVE MEDICINE ASSOC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 07/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4035 POWELTON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-2262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-471-7000
-----------------------------------------------------
Fax | 215-474-0451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3847 NORTH SYDENHAM STREET
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-227-3300
-----------------------------------------------------
Fax | 215-227-3118
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OWNER
-----------------------------------------------------
Name | RANDALL TERENCE DRAIN SR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 215-227-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD039729L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------