1558474189 NPI number — SAMARITAN OB GYN INC

Table of content: (NPI 1558474189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558474189 NPI number — SAMARITAN OB GYN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMARITAN OB GYN INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558474189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3219 CLIFTON AVE
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45220-3027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-559-9411
Provider Business Mailing Address Fax Number:
513-559-0419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1149 STONE DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
HARRISON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45030-2763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-559-9411
Provider Business Practice Location Address Fax Number:
513-559-0419
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
GRAIG
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
513-559-9411

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 36D0899783 . This is a "CLIA PPMP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0220666 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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