Provider Demographics
NPI:1912062027
Name:JEDWARD PCKERING,FACC
Entity Type:Organization
Organization Name:JEDWARD PCKERING,FACC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKERING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-642-0100
Mailing Address - Street 1:100 E LANCASTER AVE
Mailing Address - Street 2:316 LANKENAU MED BLDG
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:610-642-0100
Mailing Address - Fax:610-642-0919
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:SUITE 316 LANKENAU MED BLDG
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:610-642-0100
Practice Address - Fax:610-642-0919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA007173E261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB33117Medicare UPIN
PA018435Medicare ID - Type Unspecified