MEDICARE: PREMIER PEDIATRICS, LLC

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	208000000X	Pediatrics Physician	MD417182	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902829922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER PEDIATRICS, LLC

Provider Business Mailing Address
First Line	:	2318 E ALLEGHENY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19134-4432
Country	:	US
Telephone Number	:	215-423-1011
Fax Number	:	215-423-6743

Provider Business Practice Location Address
First Line	:	2318 E ALLEGHENY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19134-4432
Country	:	US
Telephone Number	:	215-423-1011
Fax Number	:	215-423-6743

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. JENNIFER DANA DIABO
Credential	:	MD
Telephone Number	:	215-423-1011

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	08/22/2020

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