Provider Demographics
NPI:1477588135
Name:CITY LINE PEDIATRICS
Entity Type:Organization
Organization Name:CITY LINE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-871-1800
Mailing Address - Street 1:4190 CITY AVE
Mailing Address - Street 2:SUITE 540
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1626
Mailing Address - Country:US
Mailing Address - Phone:215-871-1800
Mailing Address - Fax:215-871-1807
Practice Address - Street 1:4190 CITY AVE
Practice Address - Street 2:SUITE 540
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:215-871-1800
Practice Address - Fax:215-871-1807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S005355L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty