Basic Information
| Provider Information | |||||||||
| NPI: | 1447544697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAMAT | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | WEDIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEDIN | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | DANIELLE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD STE 9NW | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
| Address2: | CHILDRENS HOSPITAL OF PHILADELPHIA | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155902164 | ||||||||
| FaxNumber: | 2155902180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2011 | ||||||||
| LastUpdateDate: | 08/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD451398 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080H0002X | MD451398 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD451398 | 05 | PA | MEDICAID |