Provider Demographics
NPI:1417927179
Name:TEDESCO, PAMELA A (DO)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:A
Last Name:TEDESCO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1161 MCDERMOTT DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-4064
Mailing Address - Country:US
Mailing Address - Phone:610-701-7011
Mailing Address - Fax:610-429-5199
Practice Address - Street 1:1161 MCDERMOTT DR
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4064
Practice Address - Country:US
Practice Address - Phone:610-701-7011
Practice Address - Fax:610-429-5199
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007895L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001903329Medicaid
PA232359401OtherMAIN LINE HEALTHCARE
PA001903329Medicaid
PA058347HK1Medicare PIN