Healthcare Provider Details

I. General information

NPI: 1578842720
Provider Name (Legal Business Name): IMPACT PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 BETHEL RD
COLUMBUS OH
43220-1864
US

IV. Provider business mailing address

1910 BETHEL RD
COLUMBUS OH
43220-1864
US

V. Phone/Fax

Practice location:
  • Phone: 614-824-2546
  • Fax: 614-824-2549
Mailing address:
  • Phone: 614-824-2546
  • Fax: 614-824-2549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. DAWN HACKSHAW
Title or Position: OWNER
Credential: MD
Phone: 614-459-6510