Provider Demographics
NPI:1992447502
Name:HOMETOWN PEDIATRICS, LLC
Entity type:Organization
Organization Name:HOMETOWN PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPNP
Authorized Official - Prefix:
Authorized Official - First Name:THRESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GROTHAUS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:419-236-3434
Mailing Address - Street 1:308 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45830-1122
Mailing Address - Country:US
Mailing Address - Phone:419-236-3434
Mailing Address - Fax:
Practice Address - Street 1:152 W 2ND ST
Practice Address - Street 2:
Practice Address - City:DELPHOS
Practice Address - State:OH
Practice Address - Zip Code:45833-1601
Practice Address - Country:US
Practice Address - Phone:567-765-1111
Practice Address - Fax:833-940-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-13
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0133929Medicaid