MEDICARE: LIFELINE PEDIATRICS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	19922	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598896193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFELINE PEDIATRICS INC

Provider Business Mailing Address
First Line	:	100 PADUCAH DRIVE
Second Line	:
City	:	NEW MARTINSVILLE
State	:	WV
Zip	:	26155
Country	:	US
Telephone Number	:	304-455-3611
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 PADUCAH DR
Second Line	:
City	:	NEW MARTINSVILLE
State	:	WV
Zip	:	26155-2710
Country	:	US
Telephone Number	:	304-455-3611
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IBANGA M EKANEM
Credential	:	M.D.
Telephone Number	:	304-455-3611

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	08/19/2011

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Directions to “LIFELINE PEDIATRICS INC ” Practice Location

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