Healthcare Provider Details

I. General information

NPI: 1821098609
Provider Name (Legal Business Name): MARYSVILLE PEDIATRICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S PLUM ST
MARYSVILLE OH
43040-1630
US

IV. Provider business mailing address

610 S PLUM ST
MARYSVILLE OH
43040-1630
US

V. Phone/Fax

Practice location:
  • Phone: 937-644-1920
  • Fax: 937-644-2024
Mailing address:
  • Phone: 937-644-1920
  • Fax: 937-644-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-050943
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34-007191
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-083181
License Number StateOH

VIII. Authorized Official

Name: NIKOLA T ALAIN
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 937-644-1920