Provider Demographics
NPI:1821098609
Name:MARYSVILLE PEDIATRICS INC
Entity Type:Organization
Organization Name:MARYSVILLE PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NIKOLA
Authorized Official - Middle Name:T
Authorized Official - Last Name:ALAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-644-1920
Mailing Address - Street 1:610 S PLUM ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1630
Mailing Address - Country:US
Mailing Address - Phone:937-644-1920
Mailing Address - Fax:937-644-2024
Practice Address - Street 1:610 S PLUM ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1630
Practice Address - Country:US
Practice Address - Phone:937-644-1920
Practice Address - Fax:937-644-2024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-083181208000000X
OH35-050943208000000X
OH34-007191208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2244016Medicaid
I16855Medicare UPIN
I15808Medicare UPIN
OH2244016Medicaid