Provider Demographics
NPI:1134197882
Name:SUMMERSVILLE PEDIATRICS INC.
Entity type:Organization
Organization Name:SUMMERSVILLE PEDIATRICS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCLUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-872-7063
Mailing Address - Street 1:400 FAIRVIEW HEIGHTS RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-9308
Mailing Address - Country:US
Mailing Address - Phone:304-872-7063
Mailing Address - Fax:304-872-7080
Practice Address - Street 1:400 FAIRVIEW HEIGHTS RD
Practice Address - Street 2:SUITE 302
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-9308
Practice Address - Country:US
Practice Address - Phone:304-872-7063
Practice Address - Fax:304-872-7080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01157174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV513893Medicare PIN