Provider Demographics
NPI:1104989334
Name:WESTERVILLE PEDIATRIC SPECIALISTS, INC.
Entity type:Organization
Organization Name:WESTERVILLE PEDIATRIC SPECIALISTS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WODARCYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-508-2223
Mailing Address - Street 1:575 WESTAR CROSSING
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-7800
Mailing Address - Country:US
Mailing Address - Phone:614-508-2223
Mailing Address - Fax:614-508-2233
Practice Address - Street 1:575 WESTAR CROSSING
Practice Address - Street 2:SUITE 101
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7800
Practice Address - Country:US
Practice Address - Phone:614-508-2223
Practice Address - Fax:614-508-2233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
OH208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2288546Medicaid