Basic Information
| Provider Information | |||||||||
| NPI: | 1629116645 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S HOSPITAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDREN'S HOSPITAL MEDICAL CENTER - HOME HEALTH IV THERAPY PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3337 SOLUTIONS CENTER | ||||||||
| Address2: | BOX 773337 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606773003 | ||||||||
| 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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| 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 | 3336H0001X | 02-1346100 | OH | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0173998003 | 05 | WV | MEDICAID | 2800044 | 05 | OH | MEDICAID | 315488200 | 05 | MN | MEDICAID | 0173998002 | 05 | WV | MEDICAID | 7100001090 | 05 | KY | MEDICAID | BC8096605 | 01 | DEA NUMBER | OTHER | 02-1346100 | 01 | OH | PHARMACY LICENSE | OTHER | 3671193 | 01 | NCPDP | OTHER | 720040 | 01 | KY | LICENSE | OTHER |