Provider Demographics
NPI:1194844746
Name:PEDIATRIC ASSOCIATES OF FAIRFIELD, INC
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF FAIRFIELD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:INFANTINO
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:513-874-9460
Mailing Address - Street 1:5502 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4297
Mailing Address - Country:US
Mailing Address - Phone:513-874-9460
Mailing Address - Fax:513-874-5731
Practice Address - Street 1:5502 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-4297
Practice Address - Country:US
Practice Address - Phone:513-874-9460
Practice Address - Fax:513-874-5731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208000000X208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0135348Medicaid
OH0135348Medicaid
OH=========OtherTAX ID