Provider Demographics
NPI:1174718985
Name:MILL VALLEY PEDIATRICS, INC.
Entity type:Organization
Organization Name:MILL VALLEY PEDIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:937-578-4210
Mailing Address - Street 1:200 BRADENTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-7515
Mailing Address - Country:US
Mailing Address - Phone:614-793-1980
Mailing Address - Fax:
Practice Address - Street 1:1140 CHARLES LN
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-9797
Practice Address - Country:US
Practice Address - Phone:937-578-4210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-007098208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4060711Medicare PIN