Provider Demographics
NPI:1093129157
Name:PEDIATRIC CARE GROUP, P.C.
Entity Type:Organization
Organization Name:PEDIATRIC CARE GROUP, P.C.
Other - Org Name:PCG INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARYLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-885-8700
Mailing Address - Street 1:261 OLD YORK ROAD
Mailing Address - Street 2:SUITE 620
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046
Mailing Address - Country:US
Mailing Address - Phone:215-885-8700
Mailing Address - Fax:215-885-8795
Practice Address - Street 1:261 OLD YORK ROAD
Practice Address - Street 2:SUITE 620
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046
Practice Address - Country:US
Practice Address - Phone:215-885-8700
Practice Address - Fax:215-885-8795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC CARE GROUP, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013372830001Medicaid
PA1497162OtherBLUE SHIELD