Basic Information
Provider Information | |||||||||
NPI: | 1477576403 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BIRD | ||||||||
FirstName: | GEOFFREY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 N. 20TH ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191031454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159778100 | ||||||||
FaxNumber: | 2159778351 | ||||||||
Practice Location | |||||||||
Address1: | 34TH STREET & CIVIC CENTER BLVD. | ||||||||
Address2: | SUITE 9329 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191044399 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2155901858 | ||||||||
FaxNumber: | 2155901415 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 03/21/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD059753L | PA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0202X | MD059753L | PA | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0203X | MD059753L | PA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
ID | Type | State | Issuer | Description | 7527004 | 05 | NJ |   | MEDICAID | 183100EMD | 01 | PA | MEDICARE PTAN | OTHER | 001678010 | 05 | PA |   | MEDICAID |