1336147255 NPI number — JEFFREY M WISSER D.O.

Table of content: JEFFREY M WISSER D.O. (NPI 1336147255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336147255 NPI number — JEFFREY M WISSER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISSER
Provider First Name:
JEFFREY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1336147255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 636930
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:
45263-6930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-981-5123
Provider Business Mailing Address Fax Number:
513-981-5015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 W HIGH ST
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
LIMA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45801-3971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-227-7117
Provider Business Practice Location Address Fax Number:
419-227-2848
Provider Enumeration Date:
07/13/2005

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: 208600000X , with the licence number:  34007802 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00240059 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2332818 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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