Healthcare Provider Details

I. General information

NPI: 1619674637
Provider Name (Legal Business Name): STAR PEDIATRIC CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 WERTZ AVE NW STE A
CANTON OH
44708-4196
US

IV. Provider business mailing address

128 WERTZ AVE NW STE A
CANTON OH
44708-4196
US

V. Phone/Fax

Practice location:
  • Phone: 330-621-0553
  • Fax: 234-444-5387
Mailing address:
  • Phone: 330-621-0553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MS. ASIA ANNETTE EVERETT
Title or Position: PRESIDENT/ CEO
Credential:
Phone: 330-209-9945