Basic Information
| Provider Information | |||||||||
| NPI: | 1649238536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANCOAST | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RICHARD | ||||||||
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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: | 234 GOODMAN ST | ||||||||
| Address2: | BARRETT CENTER | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135846928 | ||||||||
| FaxNumber: | 5135844281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 01/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-036298 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RX0202X | 35-036298 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4047835 | 05 | TN | MEDICAID | 0390670 | 05 | OH | MEDICAID | 64764582 | 05 | KY | MEDICAID |