Provider Demographics
NPI:1962485177
Name:QUAKERTOWN PEDIATRIC ASSOCIATES PC
Entity Type:Organization
Organization Name:QUAKERTOWN PEDIATRIC ASSOCIATES PC
Other - Org Name:CEVALLOS & MOISE PEDIATRIC ASSOC PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:CEVALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-536-1915
Mailing Address - Street 1:99 N WEST END BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:QUAKERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18951
Mailing Address - Country:US
Mailing Address - Phone:215-536-1915
Mailing Address - Fax:215-536-9189
Practice Address - Street 1:99 N WEST END BLVD STE 110
Practice Address - Street 2:
Practice Address - City:QUAKERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18951
Practice Address - Country:US
Practice Address - Phone:215-536-1915
Practice Address - Fax:215-536-1915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016392E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011467990001Medicaid