Organization
PEDIATRIC ASSOCIATE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MANZAR MOMEN MD (OFFICE MANAGER)
(304) 842-5777
Entity
Organization
Contact information
Practice address
11 CHENOWETH DR, SUITE A, BRIDGEPORT, WV 26330-1675
(304) 842-5777
(304) 842-3318
Mailing address
11 CHENOWETH DR, SUITE A, BRIDGEPORT, WV 26330-1675
(304) 842-5777
(304) 842-3318
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
WV11941
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0037268000
—
WV
Enumeration date
10/06/2006
Last updated
08/22/2020
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