Basic Information
| Provider Information | |||||||||
| NPI: | 1073578951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FICHTENBAUM | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | JACK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2830 VICTORY PKWY | ||||||||
| Address2: | STE 310 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452063700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132453444 | ||||||||
| FaxNumber: | 5132453449 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ALBERT SABIN WAY | ||||||||
| Address2: | # 405 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452672800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135846977 | ||||||||
| FaxNumber: | 5135846040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 03/27/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-076757 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 35-076757 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 208000000X | 35-076757 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2147484 | 05 | OH | MEDICAID | 64005580 | 05 | KY | MEDICAID | 010064796 | 01 | OH | RAIL ROAD MEDICARE | OTHER | 200252570 | 05 | IN | MEDICAID |