Provider Demographics
NPI:1578689311
Name:RICHLAND PEDIATRICS, INC.
Entity Type:Organization
Organization Name:RICHLAND PEDIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-522-5454
Mailing Address - Street 1:120 STURGES AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2399
Mailing Address - Country:US
Mailing Address - Phone:419-522-5454
Mailing Address - Fax:
Practice Address - Street 1:120 STURGES AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2399
Practice Address - Country:US
Practice Address - Phone:419-522-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042404208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2300512Medicaid