Basic Information
| Provider Information | |||||||||
| NPI: | 1104137983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE OF CINCINNATI, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 WASHINGTON AVE | ||||||||
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| City: | NEWPORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410711986 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5940 MERCHANTS ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410421158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594262400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2010 | ||||||||
| LastUpdateDate: | 06/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | WENKER | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8594262400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35022 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | H12134 | 01 | KY | UPIN | OTHER |