Provider Demographics
NPI:1952416265
Name:HUNTINGTON PEDIATRIC CLINIC INC
Entity type:Organization
Organization Name:HUNTINGTON PEDIATRIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:R
Authorized Official - Last Name:COSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-522-3055
Mailing Address - Street 1:1448 10TH AVE STE 313
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3554
Mailing Address - Country:US
Mailing Address - Phone:304-522-3055
Mailing Address - Fax:
Practice Address - Street 1:1448 10TH AVE STE 313
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3554
Practice Address - Country:US
Practice Address - Phone:304-522-3055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0668737Medicaid
WV1802119000Medicaid
WV0017380002Medicaid
WV4000477000Medicaid