=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588961577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2011
-----------------------------------------------------
Last Update Date | 09/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1804 W KING ST SUITE 200
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-262-4525
-----------------------------------------------------
Fax | 304-262-4025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1804 W KING ST SUITE 200
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-262-4525
-----------------------------------------------------
Fax | 304-262-4025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/PEDIATRICIAN
-----------------------------------------------------
Name | DR. JUSTINA E EKE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 304-707-6204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 23370
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------