Basic Information
| Provider Information | |||||||||
| NPI: | 1891003208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADEGBITE-MARAVENTANO | ||||||||
| FirstName: | NICHELLE | ||||||||
| MiddleName: | SECORRA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PENN SQUARE EAST - NORTH TOWER | ||||||||
| Address2: | WANAMAKER BLDG - 9TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259232 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF PHILADELPHIA | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901000 | ||||||||
| FaxNumber: | 2155902180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2010 | ||||||||
| LastUpdateDate: | 08/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD437835 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.