Basic Information
| Provider Information | |||||||||
| NPI: | 1073668315 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ITM GERIATRIC SPECIALIST, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635627 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138917574 | ||||||||
| FaxNumber: | 5138911039 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 OAK ST | ||||||||
| Address2: | RM 645 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452061613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135696780 | ||||||||
| FaxNumber: | 5135696555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 10/07/2009 | ||||||||
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| AuthorizedOfficialLastName: | MINHAS | ||||||||
| AuthorizedOfficialFirstName: | IMRAN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5135696780 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207QG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | DF8219 | 01 | OH | RR MEDICARE | OTHER | 2958983 | 05 | OH | MEDICAID |