Provider Demographics
NPI:1083683742
Name:PEDIATRIC ASSOCIATES OF PAOLI, PC
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF PAOLI, PC
Other - Org Name:PEDIATRIC ASSOCIATES OF PAOLI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIENZLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-647-1484
Mailing Address - Street 1:17 INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1607
Mailing Address - Country:US
Mailing Address - Phone:610-647-1484
Mailing Address - Fax:610-647-7068
Practice Address - Street 1:17 INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1607
Practice Address - Country:US
Practice Address - Phone:610-647-1484
Practice Address - Fax:610-647-7068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA897325OtherBLUE SHIELD