Basic Information
| Provider Information | |||||||||
| NPI: | 1497980338 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREEN SOUTHWEST BEHAVIORAL HEALTH SERVICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRIDGEWELL HOSPITAL OF CINCINNATI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 MIRANOVA PL | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143346196 | ||||||||
| FaxNumber: | 6144617168 | ||||||||
| Practice Location | |||||||||
| Address1: | 5500 VERULAM AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452132418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135316444 | ||||||||
| FaxNumber: | 5135319444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2009 | ||||||||
| LastUpdateDate: | 05/11/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | DARLENE | ||||||||
| AuthorizedOfficialTitleorPosition: | COO/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5135316444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EVERGREEN SOUTHWEST BEHAVIORALHEALTH SERVICES LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.H.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | OH | Y | Hospitals | Psychiatric Hospital |
No ID Information.