Provider Demographics
NPI:1356409718
Name:LIBERTY SHARONVILLE PEDIATRICS
Entity type:Organization
Organization Name:LIBERTY SHARONVILLE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRINN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-563-0044
Mailing Address - Street 1:11258 LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2214
Mailing Address - Country:US
Mailing Address - Phone:513-563-0044
Mailing Address - Fax:513-563-0061
Practice Address - Street 1:11258 LEBANON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241-2214
Practice Address - Country:US
Practice Address - Phone:513-563-0044
Practice Address - Fax:513-563-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH040823174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0912570Medicaid
OH000000016767OtherANTHEM BCBS