1154429041 NPI number — ABC PEDIATRICS, PLLC

Table of content: (NPI 1154429041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154429041 NPI number — ABC PEDIATRICS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABC PEDIATRICS, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154429041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 PENNSYLVANIA AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25302-3302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-343-1863
Provider Business Mailing Address Fax Number:
304-344-1755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25302-3302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-343-1863
Provider Business Practice Location Address Fax Number:
304-344-1755
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATUSIC
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
304-343-1863

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  731 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 1451 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 15140 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 18217 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 16381 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 51D0910134 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 18804 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1003000000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1295798361 . This is a "NPI # CAROL FRAIL, MD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1922061076 . This is a "SUE ANN UPTON,MD NPI #" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0112455000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0167011000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0105170000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013971761 . This is a "NPI# BRENDA WALKER,CFNP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 4000022000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1598744757 . This is a "NPI # PENNY DIVITA,DO" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0107822000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1912961343 . This is a "NPI # JOE MATUSIC, MD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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