Provider Demographics
NPI:1720051444
Name:MEDIA PEDIATRICS
Entity Type:Organization
Organization Name:MEDIA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ELCOCK-MESSAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-565-3336
Mailing Address - Street 1:401 MOORE RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19086-7049
Mailing Address - Country:US
Mailing Address - Phone:610-565-3336
Mailing Address - Fax:484-361-5938
Practice Address - Street 1:401 MOORE RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:PA
Practice Address - Zip Code:19086-7049
Practice Address - Country:US
Practice Address - Phone:610-565-3336
Practice Address - Fax:484-367-5938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-12
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-071892-L261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH24667Medicare UPIN