Provider Demographics
NPI:1235188475
Name:SOUTH PHILADELPHIA PEDIATRICS
Entity Type:Organization
Organization Name:SOUTH PHILADELPHIA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-467-3515
Mailing Address - Street 1:1408 S. BROAD STREET FLOOR 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146
Mailing Address - Country:US
Mailing Address - Phone:215-467-3515
Mailing Address - Fax:215-467-0338
Practice Address - Street 1:1408 S. BROAD STREET FLOOR 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146
Practice Address - Country:US
Practice Address - Phone:215-467-3515
Practice Address - Fax:215-467-0338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-07
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027096410002Medicaid
PA1027885740001Medicaid
PA1025843220001Medicaid
PA1027096140001Medicaid
PA1027571930001Medicaid