1437179249 NPI number — KATHRYN WIKENHEISER-BROKAMP MD

Table of content: KATHRYN WIKENHEISER-BROKAMP MD (NPI 1437179249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437179249 NPI number — KATHRYN WIKENHEISER-BROKAMP MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIKENHEISER-BROKAMP
Provider First Name:
KATHRYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1437179249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 636256 CENTRAL CREDENTIALING
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:
45263-6256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-585-5507
Provider Business Mailing Address Fax Number:
513-585-5511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 BURNET AVE # MLC1010
Provider Second Line Business Practice Location Address:
DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45229-3026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-803-0239
Provider Business Practice Location Address Fax Number:
513-636-3924
Provider Enumeration Date:
07/21/2006

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: 207ZP0102X , with the licence number:  35-08-3105 , 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: 2424120 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11-01348 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 7890492 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 64069826 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200455000 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000302667 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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