Provider Demographics
NPI:1245780683
Name:PEDIATRIC SLEEP AND NEURO CENTER
Entity Type:Organization
Organization Name:PEDIATRIC SLEEP AND NEURO CENTER
Other - Org Name:PEDIATRIC SLEEP AND NEURO CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DZODZOMENYO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-446-1820
Mailing Address - Street 1:7811 FLINT RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-6420
Mailing Address - Country:US
Mailing Address - Phone:614-446-1820
Mailing Address - Fax:
Practice Address - Street 1:7811 FLINT RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-6420
Practice Address - Country:US
Practice Address - Phone:614-446-1820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC SLEEP AND NEURO CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-10
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2500X
OH35.070439261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64086143Medicaid
OH2502652Medicaid
OH2502652Medicaid
OHDZ4064252Medicare PIN