1902030547 NPI number — MIDWEST MEDICAL, LLC

Table of content: EMILY GRACE BLISS MD (NPI 1740930015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902030547 NPI number — MIDWEST MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST MEDICAL, LLC
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:
1902030547
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3116 MONTGOMERY RD STE C
Provider Second Line Business Mailing Address:
SUITE 166
Provider Business Mailing Address City Name:
MAINEVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45039-8606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-881-6355
Provider Business Mailing Address Fax Number:
513-842-7832

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3116 MONTGOMERY RD STE C
Provider Second Line Business Practice Location Address:
SUITE 166
Provider Business Practice Location Address City Name:
MAINEVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45039-8606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-881-6355
Provider Business Practice Location Address Fax Number:
513-842-7832
Provider Enumeration Date:
05/11/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CARROLL
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
513-881-6355

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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