Provider Demographics
NPI:1417081092
Name:MUDDY CREEK PEDIATRICS LLC
Entity Type:Organization
Organization Name:MUDDY CREEK PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:D
Authorized Official - Last Name:HABEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-398-3900
Mailing Address - Street 1:608 READING RD STE D
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-1561
Mailing Address - Country:US
Mailing Address - Phone:513-398-3900
Mailing Address - Fax:513-398-4950
Practice Address - Street 1:608 READING RD STE D
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-1561
Practice Address - Country:US
Practice Address - Phone:513-398-3900
Practice Address - Fax:513-398-4950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
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
OH000000284778OtherANTHEM BCBS