Basic Information
| Provider Information | |||||||||
| NPI: | 1164487039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ECKMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | HARRIS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636256 | ||||||||
| Address2: | CENTRAL CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135855504 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 3130 HIGHLAND AVE | ||||||||
| Address2: | ML0782 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135844503 | ||||||||
| FaxNumber: | 5135840462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 07/13/2017 | ||||||||
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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 | 35-076209 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64964075 | 05 | KY | MEDICAID | 010065383 | 01 | OH | RAIL ROAD MEDICARE | OTHER | 200246700 | 05 | IN | MEDICAID | 2137306 | 05 | OH | MEDICAID |