Provider Demographics
NPI:1386652824
Name:CHILDREN'S MEDICAL GROUP, INC., D/B/A LIBERTY PEDIATRICS
Entity Type:Organization
Organization Name:CHILDREN'S MEDICAL GROUP, INC., D/B/A LIBERTY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ABSHIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-668-8565
Mailing Address - Street 1:606 DENBIGH BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-4413
Mailing Address - Country:US
Mailing Address - Phone:757-833-0780
Mailing Address - Fax:757-833-0783
Practice Address - Street 1:12705 MCMANUS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4459
Practice Address - Country:US
Practice Address - Phone:757-668-4800
Practice Address - Fax:757-668-4828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA174005OtherANTHEM