Provider Demographics
NPI:1205879541
Name:MCMURRAY PEDIATRIC AND ADOLESCENT MEDICINE
Entity type:Organization
Organization Name:MCMURRAY PEDIATRIC AND ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONJA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DICAMILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-941-8199
Mailing Address - Street 1:6000 WATERDAM PLAZA DR
Mailing Address - Street 2:SUITE 280
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-5413
Mailing Address - Country:US
Mailing Address - Phone:724-941-8199
Mailing Address - Fax:724-942-6423
Practice Address - Street 1:6000 WATERDAM PLAZA DR
Practice Address - Street 2:SUITE 280
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-5413
Practice Address - Country:US
Practice Address - Phone:724-941-8199
Practice Address - Fax:724-942-6423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4199962080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA114750Medicare PIN