Provider Demographics
NPI:1881954287
Name:CHILDRENS DIAGNOSTIC CENTER
Entity type:Organization
Organization Name:CHILDRENS DIAGNOSTIC CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:S
Authorized Official - Last Name:SMITSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:513-558-9015
Mailing Address - Street 1:2100 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45015-1133
Mailing Address - Country:US
Mailing Address - Phone:513-868-1562
Mailing Address - Fax:513-868-1415
Practice Address - Street 1:2100 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45015-1133
Practice Address - Country:US
Practice Address - Phone:513-868-1562
Practice Address - Fax:513-868-1415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10057251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMC-07-04Medicaid
OH41177OtherCARF
OH9201131Medicare PIN