Provider Demographics
NPI:1790169860
Name:NATIONWIDE CHILDREN'S HOSPITAL
Entity Type:Organization
Organization Name:NATIONWIDE CHILDREN'S HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPORTS MEDICINE PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLUCHUROSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-355-6020
Mailing Address - Street 1:584 COUNTY LINE RD W
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-7245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:584 COUNTY LINE RD W
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7245
Practice Address - Country:US
Practice Address - Phone:614-355-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0041362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty