Provider Demographics
NPI:1720520612
Name:WESTSIDE PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:WESTSIDE PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMIN.
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:DICECCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-898-9111
Mailing Address - Street 1:4342 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-3322
Mailing Address - Country:US
Mailing Address - Phone:513-898-9111
Mailing Address - Fax:844-519-2824
Practice Address - Street 1:4342 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-3322
Practice Address - Country:US
Practice Address - Phone:513-898-9111
Practice Address - Fax:844-519-2824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3504319174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty