Provider Demographics
NPI:1053450296
Name:MED-PEDS MANAGEMENT LLC
Entity Type:Organization
Organization Name:MED-PEDS MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MGR CORP. SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JANET
Authorized Official - Last Name:MOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-623-8105
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24212-0570
Mailing Address - Country:US
Mailing Address - Phone:276-623-8105
Mailing Address - Fax:276-623-8109
Practice Address - Street 1:191 JOHNSON ST NE
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2934
Practice Address - Country:US
Practice Address - Phone:276-623-8105
Practice Address - Fax:276-623-8109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051200207R00000X
VA0101225410207R00000X
VA0101051074208000000X
VA0101059370208000000X
VA0101050628208000000X
VA0101028204208000000X
VA0024059099363LF0000X
VA0024166814363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACE1796Medicare PIN
VAC05361Medicare PIN