MEDICARE: PEDIATRIC AND ADOLESCENT MEDICINE GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician

General Provider Information

NPI Number	:	1801836671
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC AND ADOLESCENT MEDICINE GROUP

Provider Business Mailing Address
First Line	:	2129 W OREGON AVE
Second Line	:	FIRST FLOOR REAR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4131
Country	:	US
Telephone Number	:	215-462-6106
Fax Number	:	215-462-5922

Provider Business Practice Location Address
First Line	:	2129 W OREGON AVE
Second Line	:	FIRST FLOOR REAR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4131
Country	:	US
Telephone Number	:	215-462-6106
Fax Number	:	215-462-5922

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. STELLA C MAGLIOCCO
Credential	:
Telephone Number	:	215462616

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	07/21/2022

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