Healthcare Provider Details

I. General information

NPI: 1689888430
Provider Name (Legal Business Name): MUSKINGUM PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3814 JAMES CT
ZANESVILLE OH
43701-0965
US

IV. Provider business mailing address

3814 JAMES CT
ZANESVILLE OH
43701-0965
US

V. Phone/Fax

Practice location:
  • Phone: 740-454-7119
  • Fax: 740-455-5155
Mailing address:
  • Phone: 740-454-7119
  • Fax: 740-455-5155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number35041605
License Number StateOH

VIII. Authorized Official

Name: DR. OTHELLO REGAL REPUYAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 740-454-7119