Basic Information
| Provider Information | |||||||||
| NPI: | 1851794242 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDESTALS FOR WOMENS HEALTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 SUMMIT AVE | ||||||||
| Address2: | MSO PHYSICIAN BILLING | ||||||||
| City: | STEUBENVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439522667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402837597 | ||||||||
| FaxNumber: | 7402837608 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 ROSS PARK BLVD | ||||||||
| Address2: | SUITE G-2 | ||||||||
| City: | STEUBENVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439522681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403462014 | ||||||||
| FaxNumber: | 7403462013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2014 | ||||||||
| LastUpdateDate: | 02/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | YBANEZ-MORANO | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7402826390 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35.073473 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0111251 | 05 | OH | MEDICAID |