1104442516 NPI number — BEACON ORTHOPAEDICS & SPORTS MEDICINE, LTD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104442516 NPI number — BEACON ORTHOPAEDICS & SPORTS MEDICINE, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACON ORTHOPAEDICS & SPORTS MEDICINE, LTD
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:
1104442516
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6480 HARRISON AVE STE 201
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:
45247-7961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-354-7785
Provider Business Mailing Address Fax Number:
513-354-7651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 ARROW SPRINGS BLVD STE 2600
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45036-7021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-354-3700
Provider Business Practice Location Address Fax Number:
513-354-7651
Provider Enumeration Date:
06/22/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BLANKEMEYER
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
513-354-7785

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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