Provider Demographics
NPI:1851794242
Name:PEDESTALS FOR WOMENS HEALTH LLC
Entity Type:Organization
Organization Name:PEDESTALS FOR WOMENS HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:YBANEZ-MORANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-282-6390
Mailing Address - Street 1:380 SUMMIT AVE
Mailing Address - Street 2:MSO PHYSICIAN BILLING
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2667
Mailing Address - Country:US
Mailing Address - Phone:740-283-7597
Mailing Address - Fax:740-283-7608
Practice Address - Street 1:1 ROSS PARK BLVD
Practice Address - Street 2:SUITE G-2
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-2681
Practice Address - Country:US
Practice Address - Phone:740-346-2014
Practice Address - Fax:740-346-2013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-30
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.073473207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0111251Medicaid
OH0111251Medicaid