Provider Demographics
NPI:1306138458
Name:KIDZ PARADISE PEDIATRICS
Entity type:Organization
Organization Name:KIDZ PARADISE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TILLY
Authorized Official - Middle Name:EFFIE
Authorized Official - Last Name:DUNCAN-SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-999-9004
Mailing Address - Street 1:3275 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2518
Mailing Address - Country:US
Mailing Address - Phone:419-999-9004
Mailing Address - Fax:419-999-9006
Practice Address - Street 1:3275 W ELM ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2518
Practice Address - Country:US
Practice Address - Phone:419-999-9004
Practice Address - Fax:419-999-9006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.077031208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2136914Medicaid