Healthcare Provider Details

I. General information

NPI: 1285903880
Provider Name (Legal Business Name): PLAIN CITY PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 S JEFFERSON AVE STE 400
PLAIN CITY OH
43064-4137
US

IV. Provider business mailing address

5784 BONALY CT
DUBLIN OH
43016-9439
US

V. Phone/Fax

Practice location:
  • Phone: 614-570-3598
  • Fax:
Mailing address:
  • Phone: 614-570-3598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.093851
License Number StateOH

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. ALICIA DANIELLE FENN
Title or Position: PEDIATRICIAN
Credential: MD
Phone: 614-570-3598