Basic Information
| Provider Information | |||||||||
| NPI: | 1730516659 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MT. AIRY PEDIATRICS, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MT. AIRY PEDIATRICS, PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6673 GERMANTOWN AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191192252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152472996 | ||||||||
| FaxNumber: | 2152477504 | ||||||||
| Practice Location | |||||||||
| Address1: | 6673 GERMANTOWN AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191192252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152472996 | ||||||||
| FaxNumber: | 2152477504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2013 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOUIS JADOTTE | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2152472996 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000465921 | 01 | PA | BLUE SHIELD/HIGH MARK | OTHER | 1781620 | 01 | PA | UNITED HEALTHCARE | OTHER | 6524 | 01 | PA | AETNA | OTHER | 1026452 | 01 | PA | KEYSTONE MERCY | OTHER | 0055732001 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER |