Healthcare Provider Details

I. General information

NPI: 1265203384
Provider Name (Legal Business Name): LITTLE LEGENDS PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2024
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 W HIGH ST
MOUNT GILEAD OH
43338-1214
US

IV. Provider business mailing address

169 W HIGH ST
MOUNT GILEAD OH
43338-1214
US

V. Phone/Fax

Practice location:
  • Phone: 419-751-7050
  • Fax: 740-513-4628
Mailing address:
  • Phone: 419-751-7050
  • Fax: 740-513-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTIE J GRAVITT
Title or Position: OWNER
Credential: MD
Phone: 417-699-8682