Provider Demographics
NPI:1831307800
Name:PEDIATRIC PRACTICE, INC
Entity Type:Organization
Organization Name:PEDIATRIC PRACTICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GOVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BASKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-529-7780
Mailing Address - Street 1:14701 DETROIT AVE STE 730
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4182
Mailing Address - Country:US
Mailing Address - Phone:216-529-7780
Mailing Address - Fax:216-529-7432
Practice Address - Street 1:14701 DETROIT AVE STE 730
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4182
Practice Address - Country:US
Practice Address - Phone:216-529-7780
Practice Address - Fax:216-529-7432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2259087Medicaid
OH2259087Medicaid