Provider Demographics
NPI:1710080189
Name:PEDIATRIC & FAMILY PHYSICIANS OF MORGAN COUNTY INC
Entity Type:Organization
Organization Name:PEDIATRIC & FAMILY PHYSICIANS OF MORGAN COUNTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:QUARANTILLO
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:304-258-8805
Mailing Address - Street 1:81 WAR MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411
Mailing Address - Country:US
Mailing Address - Phone:304-258-8805
Mailing Address - Fax:304-258-8846
Practice Address - Street 1:81 WAR MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BERKELEY SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:25411
Practice Address - Country:US
Practice Address - Phone:304-258-8805
Practice Address - Fax:304-258-8846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17667207Q00000X
WV17621208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0108919000Medicaid
WV0054791000Medicaid
9301551Medicare ID - Type UnspecifiedGROUP
F69080Medicare UPIN
WV0054791000Medicaid
0814933Medicare ID - Type Unspecified
WV0108919000Medicaid