Provider Demographics
NPI:1861785412
Name:PEDIATRIC CLINIC, LLC
Entity type:Organization
Organization Name:PEDIATRIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:MAINA
Authorized Official - Last Name:NGANGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-733-2890
Mailing Address - Street 1:324 E ANTIETAM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5754
Mailing Address - Country:US
Mailing Address - Phone:301-733-2890
Mailing Address - Fax:301-733-2917
Practice Address - Street 1:324 E ANTIETAM ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5754
Practice Address - Country:US
Practice Address - Phone:301-733-2890
Practice Address - Fax:301-733-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVH16494Medicare UPIN