Provider Demographics
NPI:1598896193
Name:LIFELINE PEDIATRICS INC
Entity Type:Organization
Organization Name:LIFELINE PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IBANGA
Authorized Official - Middle Name:M
Authorized Official - Last Name:EKANEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-455-3611
Mailing Address - Street 1:100 PADUCAH DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155
Mailing Address - Country:US
Mailing Address - Phone:304-455-3611
Mailing Address - Fax:
Practice Address - Street 1:100 PADUCAH DR
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-2710
Practice Address - Country:US
Practice Address - Phone:304-455-3611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19922174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006383Medicaid