Healthcare Provider Details

I. General information

NPI: 1134464290
Provider Name (Legal Business Name): SUMMERSVILLE PEDIATRICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2012
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FLORENCE STREET
ANSTED WV
25812
US

IV. Provider business mailing address

400 FAIRVIEW HEIGHTS RD SUITE 302
SUMMERSVILLE WV
26651-9308
US

V. Phone/Fax

Practice location:
  • Phone: 304-872-7063
  • Fax: 304-872-7080
Mailing address:
  • Phone: 304-872-7063
  • Fax: 304-872-7080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01157
License Number StateWV

VIII. Authorized Official

Name: JOYCE MCCLUNG
Title or Position: OFFICE MANAGER
Credential:
Phone: 304-872-7063