Healthcare Provider Details

I. General information

NPI: 1538256805
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 CHENOWETH DR SUITE A
BRIDGEPORT WV
26330-1675
US

IV. Provider business mailing address

11 CHENOWETH DR SUITE A
BRIDGEPORT WV
26330-1675
US

V. Phone/Fax

Practice location:
  • Phone: 304-842-5777
  • Fax: 304-842-3318
Mailing address:
  • Phone: 304-842-5777
  • Fax: 304-842-3318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberWV11941
License Number StateWV

VIII. Authorized Official

Name: MANZAR MOMEN
Title or Position: OFFICE MANAGER
Credential: MD
Phone: 304-842-5777