1003079575 NPI number — CARRIE COOPER-FENSKE SANAN M.D.

Table of content: CARRIE COOPER-FENSKE SANAN M.D. (NPI 1003079575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003079575 NPI number — CARRIE COOPER-FENSKE SANAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANAN
Provider First Name:
CARRIE
Provider Middle Name:
COOPER-FENSKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COOPER-FENSKE
Provider Other First Name:
CARRIE
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NONE
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003079575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2830 VICTORY PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45206-1785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-584-4800
Provider Business Mailing Address Fax Number:
513-584-0479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
596 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45177-2123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-283-2588
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  01083558A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 35.095325 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: 46698 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7100211040 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0070900 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".