Basic Information
| Provider Information | |||||||||
| NPI: | 1003079575 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANAN | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | COOPER-FENSKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COOPER-FENSKE | ||||||||
| OtherFirstName: | CARRIE | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NONE | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2830 VICTORY PKWY | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452061785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135844800 | ||||||||
| FaxNumber: | 5135840479 | ||||||||
| Practice Location | |||||||||
| Address1: | 596 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451772123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372832588 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2008 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 01083558A | IN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 35.095325 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 46698 | KY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 7100211040 | 05 | KY | MEDICAID | 0070900 | 05 | OH | MEDICAID |