Provider Demographics
NPI:1821068743
Name:LANSDALE PEDIATRIC AND ADOLESCENT MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:LANSDALE PEDIATRIC AND ADOLESCENT MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GALENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-361-5040
Mailing Address - Street 1:1240 S BROAD ST STE 130
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-5395
Mailing Address - Country:US
Mailing Address - Phone:215-361-5040
Mailing Address - Fax:215-393-5441
Practice Address - Street 1:1240 S BROAD ST STE 130
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-5395
Practice Address - Country:US
Practice Address - Phone:215-361-5040
Practice Address - Fax:215-393-5441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019014780001Medicaid
PA001364745OtherPA BLUE SHIELD