Provider Demographics
NPI:1134270168
Name:PAVILION PEDIATRICS AT GREENSPRING STATION, PA
Entity type:Organization
Organization Name:PAVILION PEDIATRICS AT GREENSPRING STATION, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:GANUNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FAAP
Authorized Official - Phone:410-583-2955
Mailing Address - Street 1:10755 FALLS ROAD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4515
Mailing Address - Country:US
Mailing Address - Phone:410-583-2955
Mailing Address - Fax:410-583-2962
Practice Address - Street 1:10755 FALLS ROAD
Practice Address - Street 2:SUITE 260
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4515
Practice Address - Country:US
Practice Address - Phone:410-583-2955
Practice Address - Fax:410-583-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG29373Medicare UPIN
MDI01825Medicare UPIN
MDE25314Medicare UPIN
MDH15244Medicare UPIN
MDB70794Medicare UPIN
MDI47568Medicare UPIN