Provider Demographics
NPI:1366657918
Name:THE IDA KARLIN PEDIATRIC CENTER
Entity Type:Organization
Organization Name:THE IDA KARLIN PEDIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER, PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:OVIDIO
Authorized Official - Middle Name:
Authorized Official - Last Name:PENALVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-848-0351
Mailing Address - Street 1:319 5TH ST SW
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-5828
Mailing Address - Country:US
Mailing Address - Phone:253-848-0351
Mailing Address - Fax:
Practice Address - Street 1:319 5TH ST SW
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-5828
Practice Address - Country:US
Practice Address - Phone:253-848-0351
Practice Address - Fax:253-841-1397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60394287101Y00000X
WAPY60385056103T00000X
WAMD00015660208000000X
WAAP60312846363LP0200X
WAAP60311598363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7110653Medicaid