Provider Demographics
NPI:1568854347
Name:BLUFFTON PEDIATRICS
Entity Type:Organization
Organization Name:BLUFFTON PEDIATRICS
Other - Org Name:NEW PURPOSE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:BISH
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:419-549-5865
Mailing Address - Street 1:505 E JEFFERON STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLUFFTON
Mailing Address - State:OH
Mailing Address - Zip Code:45817-1349
Mailing Address - Country:US
Mailing Address - Phone:419-549-5865
Mailing Address - Fax:567-226-1055
Practice Address - Street 1:505 E JEFFERON STREET
Practice Address - Street 2:SUITE A
Practice Address - City:BLUFFTON
Practice Address - State:OH
Practice Address - Zip Code:45817
Practice Address - Country:US
Practice Address - Phone:419-549-5865
Practice Address - Fax:567-226-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA08524NP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2677045Medicaid