Basic Information
| Provider Information | |||||||||
| NPI: | 1508904400 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S HOSPITAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDREN'S HOSPITAL MEDICAL CENTER - HOME HEALTH NURSING | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 BURNET AVENUE | ||||||||
| Address2: | MAIL LOCATION 5021 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364225 | ||||||||
| FaxNumber: | 5136362511 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452061100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364225 | ||||||||
| FaxNumber: | 5136362511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
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| 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: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0173998001 | 05 | WV | MEDICAID | 154738668 | 05 | MI | MEDICAID | 0991468 | 05 | OH | MEDICAID | 34000232 | 05 | KY | MEDICAID |