Provider Demographics
NPI:1922524123
Name:STANFORD PEDIATRIC SURGERY, LLC
Entity Type:Organization
Organization Name:STANFORD PEDIATRIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALA
Authorized Official - Middle Name:
Authorized Official - Last Name:STANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-817-8683
Mailing Address - Street 1:ARCHWAYS PROFESSIONAL BUILDING
Mailing Address - Street 2:419 JOHNSON STREET
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-2705
Mailing Address - Country:US
Mailing Address - Phone:215-792-2058
Mailing Address - Fax:215-754-4295
Practice Address - Street 1:419 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2705
Practice Address - Country:US
Practice Address - Phone:215-792-2058
Practice Address - Fax:215-754-4295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419738208600000X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1750394037OtherNPI