Provider Demographics
NPI:1356333926
Name:CHILDRENS CHOICE PEDIATRICS INC
Entity Type:Organization
Organization Name:CHILDRENS CHOICE PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:DH
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-686-8424
Mailing Address - Street 1:3925 DARROW RD
Mailing Address - Street 2:#105
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-2600
Mailing Address - Country:US
Mailing Address - Phone:330-686-8424
Mailing Address - Fax:330-686-7810
Practice Address - Street 1:3925 DARROW RD
Practice Address - Street 2:#105
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-2600
Practice Address - Country:US
Practice Address - Phone:330-686-8424
Practice Address - Fax:330-686-7810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060329208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0847123Medicaid
F17605Medicare UPIN