Basic Information
| Provider Information | |||||||||
| NPI: | 1790727295 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MT AIRY PEDIATRICS, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7056 GERMANTOWN AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191191826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152472996 | ||||||||
| FaxNumber: | 2152477504 | ||||||||
| Practice Location | |||||||||
| Address1: | 7056 GERMANTOWN AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191191826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152472996 | ||||||||
| FaxNumber: | 2152477504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 09/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | CADY | ||||||||
| AuthorizedOfficialFirstName: | HERBERT | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2152472996 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 1781620 | 01 | PA | UNITED HEALTHCARE | OTHER | 0055732001 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 1026452 | 01 | PA | KEYSTONE MERCY | OTHER | 6524 | 01 | PA | AETNA | OTHER |