Basic Information
| Provider Information | |||||||||
| NPI: | 1669411534 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRIHEALTH PHYSICIAN PRACTICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 637676 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135285600 | ||||||||
| FaxNumber: | 5135289716 | ||||||||
| Practice Location | |||||||||
| Address1: | 3219 CLIFTON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452203027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135285600 | ||||||||
| FaxNumber: | 5135289716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 04/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | NIENABER | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5138621400 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRIHEALTH PHYSICIAN PRACTICES, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2569420 | 05 | OH | MEDICAID |