Basic Information
| Provider Information | |||||||||
| NPI: | 1548212988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HOSPITAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | ML 9013 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364225 | ||||||||
| FaxNumber: | 5136362511 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364225 | ||||||||
| FaxNumber: | 5136362511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | BROOMALL | ||||||||
| AuthorizedOfficialFirstName: | JODIANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR DIRECTOR BILLING & CODING SERV | ||||||||
| AuthorizedOfficialTelephone: | 5136365047 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 332BD1200X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Dialysis Equipment & Supplies | 3416A0800X | N | Transportation Services | Ambulance | Air Transport | 3416L0300X | N | Transportation Services | Ambulance | Land Transport | 282NC2000X | Y | Hospitals | General Acute Care Hospital | Children |
ID Information
| ID | Type | State | Issuer | Description | 01540871 | 05 | KY | MEDICAID | 55000152 | 05 | KY | MEDICAID | 001065780-0001 | 05 | PA | MEDICAID | 1473285 | 05 | OH | MEDICAID | 56014228 | 05 | KY | MEDICAID | 10198A | 05 | SC | MEDICAID | 200260070A | 05 | IN | MEDICAID | 404488860 | 05 | MI | MEDICAID | 4183703 | 05 | NJ | MEDICAID | 700093 | 05 | KY | MEDICAID | 304488850 | 05 | MI | MEDICAID | 0173998000 | 05 | WV | MEDICAID | 10454B | 05 | SC | MEDICAID | 107519900 | 05 | FL | MEDICAID | 1640 | 05 | KY | MEDICAID | 01100527 | 05 | NY | MEDICAID | 119659401 | 05 | TX | MEDICAID | 31000425 | 05 | KY | MEDICAID |