Basic Information
| Provider Information | |||||||||
| NPI: | 1083665137 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S MEDICAL SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | ML 5021 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136365013 | ||||||||
| FaxNumber: | 8662137084 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | ML 2001 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364408 | ||||||||
| FaxNumber: | 5136367337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 06/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | STULTZ | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR, MSS | ||||||||
| AuthorizedOfficialTelephone: | 5136366977 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN, CPCS, CPCSM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 207LP3000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0031704 | 05 | NJ | MEDICAID | 1012171 | 05 | VT | MEDICAID | 123442100 | 05 | WY | MEDICAID | 4401094 | 05 | TN | MEDICAID | QPA275 | 05 | SC | MEDICAID | 200073160A | 05 | OK | MEDICAID | 912592200 | 05 | FL | MEDICAID | 1172523 | 01 | KY | PASSPORT | OTHER | 168854101 | 05 | TX | MEDICAID | 0747634 | 05 | IA | MEDICAID | 08780896 | 05 | MS | MEDICAID | 001888699-0001 | 05 | PA | MEDICAID | 02800044 | 05 | NY | MEDICAID | 200318570A | 05 | IN | MEDICAID | 200421920A | 05 | KS | MEDICAID | 0001846002 | 05 | WV | MEDICAID | CH93141 | 05 | RI | MEDICAID | 2229805 | 05 | OH | MEDICAID | 65934085 | 05 | KY | MEDICAID |