1407284755 NPI number — CENTER CITY PEDIATRICS, LLC

Table of content: (NPI 1407284755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407284755 NPI number — CENTER CITY PEDIATRICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER CITY PEDIATRICS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CCP THERAPY
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407284755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1740 SOUTH ST
Provider Second Line Business Mailing Address:
STE 301
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19146-1514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-735-5600
Provider Business Mailing Address Fax Number:
215-735-5690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1740 SOUTH ST
Provider Second Line Business Practice Location Address:
STE 301
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19146-1514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-735-5600
Provider Business Practice Location Address Fax Number:
215-735-5690
Provider Enumeration Date:
10/24/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BANNETT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
215-735-5600

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SL002576L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)