Healthcare Provider Details

I. General information

NPI: 1154429041
Provider Name (Legal Business Name): ABC PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 PENNSYLVANIA AVE SUITE 200
CHARLESTON WV
25302-3302
US

IV. Provider business mailing address

830 PENNSYLVANIA AVE SUITE 200
CHARLESTON WV
25302-3302
US

V. Phone/Fax

Practice location:
  • Phone: 304-343-1863
  • Fax: 304-344-1755
Mailing address:
  • Phone: 304-343-1863
  • Fax: 304-344-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1451
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15140
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18217
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16381
License Number StateWV
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number51D0910134
License Number StateWV
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number18804
License Number StateWV
# 7
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number731
License Number StateWV

VIII. Authorized Official

Name: DR. JOSEPH MATUSIC
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 304-343-1863