Provider Demographics
NPI:1902829922
Name:PREMIER PEDIATRICS, LLC
Entity Type:Organization
Organization Name:PREMIER PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DANA
Authorized Official - Last Name:DIABO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-423-1011
Mailing Address - Street 1:2318 E ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4432
Mailing Address - Country:US
Mailing Address - Phone:215-423-1011
Mailing Address - Fax:215-423-6743
Practice Address - Street 1:2318 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4432
Practice Address - Country:US
Practice Address - Phone:215-423-1011
Practice Address - Fax:215-423-6743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD417182208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019068950003Medicaid
PA0019068950003Medicaid