Basic Information
Provider Information | |||||||||
NPI: | 1346388378 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHILDREN'S HOSPITAL MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHILDREN'S HOSPITAL MEDICAL CENTER - RETAIL PHARMACY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3337 SOLUTIONS CENTER | ||||||||
Address2: | BOX 773337 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606773003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5136364225 | ||||||||
FaxNumber: | 5136362511 | ||||||||
Practice Location | |||||||||
Address1: | 3333 BURNET AVENUE | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452293039 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5136364225 | ||||||||
FaxNumber: | 5136362511 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2007 | ||||||||
LastUpdateDate: | 01/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROOMALL | ||||||||
AuthorizedOfficialFirstName: | JODIANNE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SR DIRECTOR BILLING & CODING SERV | ||||||||
AuthorizedOfficialTelephone: | 5136365047 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CHILDREN'S HOSPITAL MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 02-0040400 | OH | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 54021670 | 05 | KY |   | MEDICAID | 200046400A | 05 | IN |   | MEDICAID | FC0147226 | 01 |   | DEA | OTHER | 0173998003 | 05 | WV |   | MEDICAID | 02-32000233 | 01 | OH | LICENSE | OTHER | 2800017 | 05 | OH |   | MEDICAID | 3629219 | 01 |   | NCPDP | OTHER |