Provider Demographics
NPI:1154860310
Name:COMPASSIONATE CARE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:COMPASSIONATE CARE PEDIATRICS, LLC
Other - Org Name:COMPASSIONATE CARE PEDS
Other - Org Type:Other Name
Authorized Official - Title/Position:SUPERVISING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-252-1948
Mailing Address - Street 1:315 HOSPITAL DR
Mailing Address - Street 2:STE 101
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1945
Mailing Address - Country:US
Mailing Address - Phone:276-252-1948
Mailing Address - Fax:
Practice Address - Street 1:315 HOSPITAL DR
Practice Address - Street 2:STE 101
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1945
Practice Address - Country:US
Practice Address - Phone:276-252-1948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056392207K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAI12188Medicare UPIN