Provider Demographics
NPI:1033750047
Name:LIFESTAGES PEDIATRICS LLC
Entity Type:Organization
Organization Name:LIFESTAGES PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-935-6493
Mailing Address - Street 1:8080 OLD YORK RD STE 207
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1426
Mailing Address - Country:US
Mailing Address - Phone:215-935-6493
Mailing Address - Fax:
Practice Address - Street 1:8080 OLD YORK RD STE 207
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-1426
Practice Address - Country:US
Practice Address - Phone:215-935-6493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025509500009Medicaid