Provider Demographics
NPI:1497730550
Name:PREMIUM PEDIATRICS
Entity Type:Organization
Organization Name:PREMIUM PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OKLOTA-FADELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-652-3100
Mailing Address - Street 1:918 YOUNGSTOWN WARREN RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446-4623
Mailing Address - Country:US
Mailing Address - Phone:330-652-3100
Mailing Address - Fax:330-652-1231
Practice Address - Street 1:918 YOUNGSTOWN WARREN RD
Practice Address - Street 2:SUITE C
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-4623
Practice Address - Country:US
Practice Address - Phone:330-652-3100
Practice Address - Fax:330-652-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2600760Medicaid