Provider Demographics
NPI:1083694798
Name:1201 PEDIATRIC GROUP
Entity Type:Organization
Organization Name:1201 PEDIATRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOMZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-525-2180
Mailing Address - Street 1:1201 COUNTY LINE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-2636
Mailing Address - Country:US
Mailing Address - Phone:610-525-3335
Mailing Address - Fax:610-527-2773
Practice Address - Street 1:1201 COUNTY LINE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-2636
Practice Address - Country:US
Practice Address - Phone:610-525-2180
Practice Address - Fax:215-527-2773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA077524Medicare ID - Type Unspecified