Provider Demographics
NPI:1801836671
Name:PEDIATRIC AND ADOLESCENT MEDICINE GROUP
Entity Type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT MEDICINE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MAGLIOCCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:21-546-2616
Mailing Address - Street 1:2129 W OREGON AVE
Mailing Address - Street 2:FIRST FLOOR REAR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4131
Mailing Address - Country:US
Mailing Address - Phone:215-462-6106
Mailing Address - Fax:215-462-5922
Practice Address - Street 1:2129 W OREGON AVE
Practice Address - Street 2:FIRST FLOOR REAR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4131
Practice Address - Country:US
Practice Address - Phone:215-462-6106
Practice Address - Fax:215-462-5922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty