Healthcare Provider Details

I. General information

NPI: 1609837038
Provider Name (Legal Business Name): THE PEDIATRIC HEALTHCARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 HAGER ST
ST MARYS OH
45885
US

IV. Provider business mailing address

1010 HAGER ST
SAINT MARYS OH
45885-2421
US

V. Phone/Fax

Practice location:
  • Phone: 419-394-2610
  • Fax: 419-394-6605
Mailing address:
  • Phone: 419-394-2610
  • Fax: 419-394-6605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35068454
License Number StateOH

VIII. Authorized Official

Name: CHERYL KUCK
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 419-394-2610