Healthcare Provider Details

I. General information

NPI: 1720107097
Provider Name (Legal Business Name): WEST SIDE ADULT AND PEDIATRIC CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7225 COLERAIN AVE SUITE 103
CINCINNATI OH
45239-5329
US

IV. Provider business mailing address

7225 COLERAIN AVE SUITE 103
CINCINNATI OH
45239-5329
US

V. Phone/Fax

Practice location:
  • Phone: 513-681-3500
  • Fax: 513-681-1391
Mailing address:
  • Phone: 513-681-3500
  • Fax: 513-681-1391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: KYLIE BOGGS
Title or Position: OFFICE MANAGER
Credential:
Phone: 513-681-3500