Basic Information
| Provider Information | |||||||||
| NPI: | 1912284118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HADDAD | ||||||||
| FirstName: | 393AMANDA | ||||||||
| MiddleName: | JENNIFER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GEDNEY | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | JENNIFER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2743 MARBLEVISTA BLVD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432049016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407598709 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4255 NORTHFIELD RD | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND HILLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441282811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162929700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 11/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT.013498 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0028740 | 05 | OH | MEDICAID |