Healthcare Provider Details

I. General information

NPI: 1205356466
Provider Name (Legal Business Name): WEST SIDE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7074 HARRISON AVE
CINCINNATI OH
45247
US

IV. Provider business mailing address

663 ANDERSON FERRY RD
CINCINNATI OH
45238
US

V. Phone/Fax

Practice location:
  • Phone: 513-922-8200
  • Fax: 513-347-0082
Mailing address:
  • Phone: 513-922-8200
  • Fax: 513-347-0082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: JANIE TEBBEN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 513-347-5083