=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528375839
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BALGOPAL ERADI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2010
-----------------------------------------------------
Last Update Date | 09/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3333 BURNET AVE CINCINNATI CHILDRENS HOSPITAL MEDICAL CENTRE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-636-4200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1216 PAXTON AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45208-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-321-1970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0120X
-----------------------------------------------------
Taxonomy Name | Pediatric Surgery Physician
-----------------------------------------------------
License Number | 57.017437
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------