1548297807 NPI number — QUEEN CITY GENERAL & VASCULAR SURGEONS GROUP LTD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548297807 NPI number — QUEEN CITY GENERAL & VASCULAR SURGEONS GROUP LTD

Employer Identification Number (EIN):

Provider Organization Name:

QUEEN CITY GENERAL & VASCULAR SURGEONS GROUP 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 Other Organization Name:

QUEEN CITY SURGICAL CONSULTANTS

Provider Other Organization Name Type Code:

3

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:

1548297807

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

11/22/2011

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1270 SOLUTIONS CENTER

Provider Second Line Business Mailing Address:

PO BOX 771270

Provider Business Mailing Address City Name:

CHICAGO

Provider Business Mailing Address State Name:

IL

Provider Business Mailing Address Postal Code:

60677-1002

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

513-542-6898

Provider Business Mailing Address Fax Number:

513-542-7972

Provider First Line Business Practice Location Address:

7502 STATE RD

Provider Second Line Business Practice Location Address:

STE. 1180

Provider Business Practice Location Address City Name:

CINCINNATI

Provider Business Practice Location Address State Name:

OH

Provider Business Practice Location Address Postal Code:

45255-2800

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

513-232-8181

Provider Business Practice Location Address Fax Number:

513-624-2964

Provider Enumeration Date:

06/26/2006

Authorized Official Last Name:

ERTEL

Authorized Official First Name:

PEGGY

Authorized Official Middle Name:

Authorized Official Title or Position:

PRACTICE MANAGER

Authorized Official Telephone Number:

513-232-8181

• Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 200293310B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 2066026 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 2066035 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 2066044 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 200293310E , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 2065867 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 2324336 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 200293310A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200293310C , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200293310D , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: CD8400 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 2066053 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 2066017 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".