Provider Demographics
NPI:1457301616
Name:BUBOLZ, BETH ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:ANN
Last Name:BUBOLZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHILDRENS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2664
Mailing Address - Country:US
Mailing Address - Phone:614-722-2000
Mailing Address - Fax:614-722-4380
Practice Address - Street 1:7853 PACER DR
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-7571
Practice Address - Country:US
Practice Address - Phone:614-355-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0873332080P0204X
MO20030058592080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2989011Medicaid
OHBU4274691Medicare PIN
269C276Medicare ID - Type Unspecified
MO208378919Medicaid
OH2989011Medicaid