Basic Information
| Provider Information | |||||||||
| NPI: | 1053464305 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHMC COMMUNITY HEALTH SERVICES NETWORK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDREN'S HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 BURNET AVENUE ML 5021 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364225 | ||||||||
| FaxNumber: | 5136362511 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 STATE ROAD 46 WEST | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470061487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129336000 | ||||||||
| FaxNumber: | 8129336013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUTHRIE | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR MEDICAL STAFF SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5136369691 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MS, CPMSM, CPCS | ||||||||
| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200122080A | 05 | IN | MEDICAID | 0264271 | 05 | OH | MEDICAID |