Provider Demographics
NPI:1205356466
Name:WEST SIDE PEDIATRICS
Entity Type:Organization
Organization Name:WEST SIDE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TEBBEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-347-5083
Mailing Address - Street 1:663 ANDERSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238
Mailing Address - Country:US
Mailing Address - Phone:513-922-8200
Mailing Address - Fax:513-347-0082
Practice Address - Street 1:7074 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247
Practice Address - Country:US
Practice Address - Phone:513-922-8200
Practice Address - Fax:513-347-0082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0954794Medicaid