Healthcare Provider Details

I. General information

NPI: 1366443301
Provider Name (Legal Business Name): RICHLAND PEDIATRICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 STURGES AVE STE 1
MANSFIELD OH
44903
US

IV. Provider business mailing address

120 STURGES AVE STE 1
MANSFIELD OH
44903
US

V. Phone/Fax

Practice location:
  • Phone: 419-522-5454
  • Fax: 419-522-2981
Mailing address:
  • Phone: 419-522-5454
  • Fax: 419-522-2981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35042404S
License Number StateOH

VIII. Authorized Official

Name: DR. CHANDRA R SHAKER
Title or Position: PRESIDENT
Credential: MDFAAP
Phone: 419-522-5454