Healthcare Provider Details

I. General information

NPI: 1205936291
Provider Name (Legal Business Name): PEDIATRIC CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MEDICAL PARK STE 202
WHEELING WV
26003-6391
US

IV. Provider business mailing address

30 MEDICAL PARK STE 202
WHEELING WV
26003-6391
US

V. Phone/Fax

Practice location:
  • Phone: 304-243-1250
  • Fax: 304-243-1518
Mailing address:
  • Phone: 304-243-1250
  • Fax: 304-243-1518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. LAURA R BLOSSER
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 304-243-1250