Healthcare Provider Details

I. General information

NPI: 1023087574
Provider Name (Legal Business Name): KIDDIE WEST PEDIATRICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4766 W BROAD ST
COLUMBUS OH
43228-1613
US

IV. Provider business mailing address

4766 W BROAD ST
COLUMBUS OH
43228-1613
US

V. Phone/Fax

Practice location:
  • Phone: 614-851-7337
  • Fax: 614-851-0080
Mailing address:
  • Phone: 614-851-7337
  • Fax: 614-851-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34-00-2237
License Number StateOH

VIII. Authorized Official

Name: DR. CARL R BACKES
Title or Position: PRESIDENT
Credential: D.O.
Phone: 614-851-7337