Healthcare Provider Details

I. General information

NPI: 1306138458
Provider Name (Legal Business Name): KIDZ PARADISE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2011
Last Update Date: 05/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3275 W ELM ST
LIMA OH
45805-2518
US

IV. Provider business mailing address

3275 W ELM ST
LIMA OH
45805-2518
US

V. Phone/Fax

Practice location:
  • Phone: 419-999-9004
  • Fax: 419-999-9006
Mailing address:
  • Phone: 419-999-9004
  • Fax: 419-999-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.077031
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2136914
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: DR. TILLY EFFIE DUNCAN-SAMPSON
Title or Position: OWNER
Credential:
Phone: 419-999-9004