Provider Demographics
NPI:1396822847
Name:GREEN ROAD PEDIATRICS, INC.
Entity Type:Organization
Organization Name:GREEN ROAD PEDIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-382-3800
Mailing Address - Street 1:1611 S GREEN RD
Mailing Address - Street 2:SUITE 035
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-4128
Mailing Address - Country:US
Mailing Address - Phone:216-382-3800
Mailing Address - Fax:216-381-5198
Practice Address - Street 1:1611 S GREEN RD
Practice Address - Street 2:SUITE 035
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-4128
Practice Address - Country:US
Practice Address - Phone:216-382-3800
Practice Address - Fax:216-381-5198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2129637Medicaid
OH2129637Medicaid