Provider Demographics
NPI:1720248891
Name:MID-OHIO PEDIATRICS AND ADOLESCENTS, INC.
Entity type:Organization
Organization Name:MID-OHIO PEDIATRICS AND ADOLESCENTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-899-0000
Mailing Address - Street 1:595 COPELAND MILL RD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8908
Mailing Address - Country:US
Mailing Address - Phone:614-899-0000
Mailing Address - Fax:614-794-7597
Practice Address - Street 1:595 COPELAND MILL RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8908
Practice Address - Country:US
Practice Address - Phone:614-899-0000
Practice Address - Fax:614-794-7597
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDOHIO PEDIATRICS & ADOLESCENTS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-12
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0784021Medicaid