Provider Demographics
NPI:1740337799
Name:MID-CITY PEDIATRICS, INC
Entity type:Organization
Organization Name:MID-CITY PEDIATRICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-948-8444
Mailing Address - Street 1:8250 KENWOOD CROSSING WAY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-3668
Mailing Address - Country:US
Mailing Address - Phone:513-948-8444
Mailing Address - Fax:513-948-0756
Practice Address - Street 1:8250 KENWOOD CROSSING WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-3668
Practice Address - Country:US
Practice Address - Phone:513-948-8444
Practice Address - Fax:513-948-0756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-4973-G208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0784030Medicaid