Provider Demographics
NPI:1356443543
Name:THE PEDIATRIC & ADOLESCENT MEDICINE CENTERS OF PHILADELPHIA
Entity Type:Organization
Organization Name:THE PEDIATRIC & ADOLESCENT MEDICINE CENTERS OF PHILADELPHIA
Other - Org Name:PAMCOP
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUFFMAN-DEVAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-848-9000
Mailing Address - Street 1:105 W SCHOOLHOUSE LANE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144
Mailing Address - Country:US
Mailing Address - Phone:215-848-9000
Mailing Address - Fax:215-848-7894
Practice Address - Street 1:105 W SCHOOLHOUSE LANE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144
Practice Address - Country:US
Practice Address - Phone:215-848-9000
Practice Address - Fax:215-848-7894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032197E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01273236Medicaid
PA01273236Medicaid