Healthcare Provider Details

I. General information

NPI: 1205969029
Provider Name (Legal Business Name): STAR PEDIATRICS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1659 W 2ND ST
XENIA OH
45385-4205
US

IV. Provider business mailing address

1659 W 2ND ST
XENIA OH
45385-4205
US

V. Phone/Fax

Practice location:
  • Phone: 937-376-5437
  • Fax: 937-376-8038
Mailing address:
  • Phone: 937-376-5437
  • Fax: 937-376-8038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

# 1
Identifier2033516
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: KIM BOND
Title or Position: OFFICE MANAGER
Credential:
Phone: 937-376-5437