Basic Information
| Provider Information | |||||||||
| NPI: | 1205871357 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTIAGO | ||||||||
| FirstName: | AMELIA | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 LYNN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255231138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048245806 | ||||||||
| FaxNumber: | 3048245804 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 LARRY JOE HARLESS DRIVE, SUITE 205 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 256211842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046646270 | ||||||||
| FaxNumber: | 3046646272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 03/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 21670 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 12861 | WV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0112321000 | 05 | WV | MEDICAID | 65920951 | 05 | KY | MEDICAID |