Provider Demographics
NPI:1356541650
Name:PEDIATRIC SERVICE GROUP
Entity type:Organization
Organization Name:PEDIATRIC SERVICE GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:
Authorized Official - Last Name:IQBAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-759-9670
Mailing Address - Street 1:1044 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1006
Mailing Address - Country:US
Mailing Address - Phone:330-759-9670
Mailing Address - Fax:330-759-9705
Practice Address - Street 1:4308 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1052
Practice Address - Country:US
Practice Address - Phone:330-759-9670
Practice Address - Fax:330-759-9705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043505173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty