Provider Demographics
NPI:1578842720
Name:IMPACT PEDIATRICS, LLC
Entity Type:Organization
Organization Name:IMPACT PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-459-6510
Mailing Address - Street 1:1910 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-1864
Mailing Address - Country:US
Mailing Address - Phone:614-824-2546
Mailing Address - Fax:614-824-2549
Practice Address - Street 1:1910 BETHEL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-1864
Practice Address - Country:US
Practice Address - Phone:614-824-2546
Practice Address - Fax:614-824-2549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0051229Medicaid