Provider Demographics
NPI:1437405602
Name:EXECUTIVE MEWS PEDIATRICS, LLC
Entity Type:Organization
Organization Name:EXECUTIVE MEWS PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-830-8870
Mailing Address - Street 1:2300 COMPUTER AVE
Mailing Address - Street 2:SUITE H-44
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1742
Mailing Address - Country:US
Mailing Address - Phone:215-830-8870
Mailing Address - Fax:
Practice Address - Street 1:2300 COMPUTER AVE
Practice Address - Street 2:SUITE H-44
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1742
Practice Address - Country:US
Practice Address - Phone:215-830-8870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD063137L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017043070004Medicaid
PAG77003Medicare UPIN