Basic Information
| Provider Information | |||||||||
| NPI: | 1992050009 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NATIONWIDE CHILDREN'S HOSPITAL, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NATIONWIDE CHILDREN'S HOSPITAL BEHAVIORAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 E MAIN ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143550511 | ||||||||
| FaxNumber: | 6143550509 | ||||||||
| Practice Location | |||||||||
| Address1: | 399 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558550 | ||||||||
| FaxNumber: | 6143558593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2012 | ||||||||
| LastUpdateDate: | 07/27/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOFFMAN | ||||||||
| AuthorizedOfficialFirstName: | AILEEN | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | BEHAVIORAL HEALTH OPERATIONS MANAGE | ||||||||
| AuthorizedOfficialTelephone: | 6143550511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 08258 | 05 | OH | MEDICAID |