Provider Demographics
NPI:1639251036
Name:SOUTH CHARLESTON PEDIATRICS
Entity Type:Organization
Organization Name:SOUTH CHARLESTON PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-982-7334
Mailing Address - Street 1:830 PENNSYLVANIA AVENUE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302
Mailing Address - Country:US
Mailing Address - Phone:304-982-7031
Mailing Address - Fax:304-766-9450
Practice Address - Street 1:830 PENNSYLVANIA AVENUE
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302
Practice Address - Country:US
Practice Address - Phone:304-982-7031
Practice Address - Fax:304-766-9450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4005199000Medicaid