Provider Demographics
NPI:1154429041
Name:ABC PEDIATRICS, PLLC
Entity type:Organization
Organization Name:ABC PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MATUSIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-343-1863
Mailing Address - Street 1:830 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3302
Mailing Address - Country:US
Mailing Address - Phone:304-343-1863
Mailing Address - Fax:304-344-1755
Practice Address - Street 1:830 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3302
Practice Address - Country:US
Practice Address - Phone:304-343-1863
Practice Address - Fax:304-344-1755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV731208000000X
WV1451208000000X
WV15140208000000X
WV18217208000000X
WV16381208000000X
WV51D0910134291U00000X
WV18804363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1003000000Medicaid
WV1295798361OtherNPI # CAROL FRAIL, MD
WV1922061076OtherSUE ANN UPTON,MD NPI #
WV0112455000Medicaid
WV0167011000Medicaid
WV0105170000Medicaid
WV1013971761OtherNPI# BRENDA WALKER,CFNP
WV4000022000Medicaid
WV1598744757OtherNPI # PENNY DIVITA,DO
WV0107822000Medicaid
WV1912961343OtherNPI # JOE MATUSIC, MD
WV1912961343OtherNPI # JOE MATUSIC, MD
WVF53257Medicare UPIN
WV0792053Medicare ID - Type UnspecifiedMEDICARE # PENNY DIVITA
WV1922061076OtherSUE ANN UPTON,MD NPI #
WVG15685Medicare UPIN
WV0167011000Medicaid