Provider Demographics
NPI:1407876295
Name:SUBURBAN PULMONARY MEDICINE, P. C.
Entity Type:Organization
Organization Name:SUBURBAN PULMONARY MEDICINE, P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-521-1300
Mailing Address - Street 1:1 BARTOL AVE
Mailing Address - Street 2:SUITE 14
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-2214
Mailing Address - Country:US
Mailing Address - Phone:610-521-1300
Mailing Address - Fax:610-521-9074
Practice Address - Street 1:1 BARTOL AVE
Practice Address - Street 2:SUITE 14
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-2214
Practice Address - Country:US
Practice Address - Phone:610-521-1300
Practice Address - Fax:610-521-9074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA668795Medicare UPIN
PA668795Medicare ID - Type Unspecified