Provider Demographics
NPI:1447311576
Name:PEDIATRIC & PREVENTIVE MEDICINE ASSOC PC
Entity type:Organization
Organization Name:PEDIATRIC & PREVENTIVE MEDICINE ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:TERENCE
Authorized Official - Last Name:DRAIN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:215-227-3300
Mailing Address - Street 1:3847 NORTH SYDENHAM STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140
Mailing Address - Country:US
Mailing Address - Phone:215-227-3300
Mailing Address - Fax:215-227-3118
Practice Address - Street 1:4035 POWELTON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2262
Practice Address - Country:US
Practice Address - Phone:215-471-7000
Practice Address - Fax:215-474-0451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039729L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1054660Medicaid
B41554Medicare UPIN