Healthcare Provider Details

I. General information

NPI: 1497730550
Provider Name (Legal Business Name): PREMIUM PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 YOUNGSTOWN WARREN RD SUITE C
NILES OH
44446-4623
US

IV. Provider business mailing address

918 YOUNGSTOWN WARREN RD SUITE C
NILES OH
44446-4623
US

V. Phone/Fax

Practice location:
  • Phone: 330-652-3100
  • Fax: 330-652-1231
Mailing address:
  • Phone: 330-652-3100
  • Fax: 330-652-1231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CARRIE OKLOTA-FADELL
Title or Position: PRESIDENT
Credential: MD
Phone: 330-652-3100