Provider Demographics
NPI:1417922782
Name:MERCY PEDIATRIC ASSOCIATES PC
Entity Type:Organization
Organization Name:MERCY PEDIATRIC ASSOCIATES PC
Other - Org Name:LANSDOWNE PARK PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GENOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-237-4995
Mailing Address - Street 1:1503 LANSDOWNE AVE
Mailing Address - Street 2:STE 3002
Mailing Address - City:DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19023
Mailing Address - Country:US
Mailing Address - Phone:610-237-4995
Mailing Address - Fax:610-237-7311
Practice Address - Street 1:1503 LANSDOWNE AVE
Practice Address - Street 2:STE 3002
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023
Practice Address - Country:US
Practice Address - Phone:610-237-4995
Practice Address - Fax:610-237-7311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2011-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0464621001OtherIBC
0018123OtherUSHC
PA0014441550002Medicaid
634564OtherBS
0297647OtherCIGNA