Provider Demographics
NPI:1487987020
Name:FAIRMOUNT PEDIATRICS AND ADOLESCENT MEDICINE
Entity type:Organization
Organization Name:FAIRMOUNT PEDIATRICS AND ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:LIEBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-774-1166
Mailing Address - Street 1:7042 GREENE ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-3439
Mailing Address - Country:US
Mailing Address - Phone:215-990-6625
Mailing Address - Fax:215-279-8383
Practice Address - Street 1:2000 HAMILTON ST
Practice Address - Street 2:#109
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19130-3814
Practice Address - Country:US
Practice Address - Phone:215-774-1166
Practice Address - Fax:215-279-8383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059659L261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care