Basic Information
| Provider Information | |||||||||
| NPI: | 1144229899 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREATER CINCINNATI CARDIOVASCULAR CONSULTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2123 AUBURN AVENUE | ||||||||
| Address2: | SUITE 624 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137514222 | ||||||||
| FaxNumber: | 5137514353 | ||||||||
| Practice Location | |||||||||
| Address1: | 2123 AUBURN AVENUE | ||||||||
| Address2: | SUITE 624 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137514222 | ||||||||
| FaxNumber: | 5137514353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 09/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | JENIKE | ||||||||
| AuthorizedOfficialFirstName: | F. THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5137514222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35031105 | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 845447 | 05 | OH | MEDICAID | 000000015271 | 01 | ANTHEM | OTHER | 65919193 | 05 | KY | MEDICAID | 100028740 | 05 | IN | MEDICAID |