MEDICARE: KIDDIE WEST PEDIATRICS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	34-00-2237	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023087574
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDDIE WEST PEDIATRICS INC

Provider Business Mailing Address
First Line	:	4766 W BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-1613
Country	:	US
Telephone Number	:	614-851-7337
Fax Number	:	614-851-0080

Provider Business Practice Location Address
First Line	:	4766 W BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-1613
Country	:	US
Telephone Number	:	614-851-7337
Fax Number	:	614-851-0080

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CARL R BACKES
Credential	:	D.O.
Telephone Number	:	614-851-7337

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/16/2009

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