Provider Demographics
NPI:1093084584
Name:CARO PEDIATRIC CENTER
Entity Type:Organization
Organization Name:CARO PEDIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-275-8559
Mailing Address - Street 1:1435 SHOUP MILL RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-3978
Mailing Address - Country:US
Mailing Address - Phone:937-275-3488
Mailing Address - Fax:937-275-3371
Practice Address - Street 1:1435 SHOUP MILL RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-3978
Practice Address - Country:US
Practice Address - Phone:937-275-3488
Practice Address - Fax:937-275-3371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-056515-C208000000X
OH34-002567208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0535326Medicaid
OH0696180Medicaid