Provider Demographics
NPI:1821287640
Name:PEDIATRIC CARE
Entity Type:Organization
Organization Name:PEDIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLOSSER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-243-1250
Mailing Address - Street 1:30 MEDICAL PARK
Mailing Address - Street 2:STE 202
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6391
Mailing Address - Country:US
Mailing Address - Phone:304-243-1250
Mailing Address - Fax:304-243-1518
Practice Address - Street 1:30 MEDICAL PARK
Practice Address - Street 2:STE 202
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6391
Practice Address - Country:US
Practice Address - Phone:304-243-1250
Practice Address - Fax:304-243-1518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV291U00000XOtherTAXONOMY CODE
WV3810001840Medicaid