Provider Demographics
NPI:1093776247
Name:INFANTS CHILDREN AND YOUTH
Entity Type:Organization
Organization Name:INFANTS CHILDREN AND YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-752-0382
Mailing Address - Street 1:320 MIDDLETOWN BLVD
Mailing Address - Street 2:THE COURTYARD SUITE 300
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-3204
Mailing Address - Country:US
Mailing Address - Phone:215-752-0382
Mailing Address - Fax:215-752-4807
Practice Address - Street 1:320 MIDDLETOWN BLVD
Practice Address - Street 2:THE COURTYARD SUITE 300
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-3204
Practice Address - Country:US
Practice Address - Phone:215-752-0382
Practice Address - Fax:215-752-4807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003032L174400000X
PAOS004790L174400000X
PAMD032401E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG25360Medicare UPIN
PAB40835Medicare UPIN
PAE64106Medicare UPIN