Provider First Line Business Practice Location Address: 
CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER
    Provider Second Line Business Practice Location Address: 
3333 BURNET AVENUE, ML 5043
    Provider Business Practice Location Address City Name: 
CINCINNATI
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
45229-3026
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
513-636-4211
    Provider Business Practice Location Address Fax Number: 
513-636-5887
    Provider Enumeration Date: 
03/15/2013