Basic Information
| Provider Information | |||||||||
| NPI: | 1205090917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOBERLEIN | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | ML 5031 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364251 | ||||||||
| FaxNumber: | 5136368145 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | ML 5031 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364251 | ||||||||
| FaxNumber: | 5136368145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2008 | ||||||||
| LastUpdateDate: | 07/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301092934 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 2014-00570 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 35.120906 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085P0229X | 35.120906 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 5114457 | 01 | NC | UNITED HEALTHCARE | OTHER | 1205090917 | 05 | NC | MEDICAID | Q70014 | 01 | SC | SC MEDICAID | OTHER | 1205090917 | 01 | NC | TRICARE | OTHER | 1868W | 01 | NC | BCBS | OTHER | 4105367 | 01 | NC | AETNA | OTHER | 1205090917 | 01 | VA | VIRGINIA MEDICAID | OTHER | 281983 | 01 | NC | MEDCOST | OTHER |