Basic Information
Provider Information | |||||||||
NPI: | 1154318210 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SKINNER | ||||||||
FirstName: | CHERYL | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 842 CARSON DR | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | OH | ||||||||
PostalCode: | 450361316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5133254392 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 ARROW SPRINGS BLVD | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | OH | ||||||||
PostalCode: | 450367002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5134514033 | ||||||||
FaxNumber: | 5134511356 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2005 | ||||||||
LastUpdateDate: | 08/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 35048340 | OH | N |   | Other Service Providers | Specialist |   | 207RH0003X | 35048340 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 0636217 | 05 | OH |   | MEDICAID |