Basic Information
Provider Information | |||||||||
NPI: | 1184691230 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANDERS | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | BRYNA KATZ | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 237 WILLIAM HOWARD TAFT, PHYS. DIV. | ||||||||
Address2: | 2ND FL, CBO2-3, ATTN: CREDENTIALING | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452192906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132638571 | ||||||||
FaxNumber: | 5132638622 | ||||||||
Practice Location | |||||||||
Address1: | 4440 RED BANK ROAD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452272172 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5135645000 | ||||||||
FaxNumber: | 5135644925 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2006 | ||||||||
LastUpdateDate: | 10/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | 35-086334 | OH | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
ID | Type | State | Issuer | Description | 2577019 | 05 | OH |   | MEDICAID | 64101827 | 05 | KY |   | MEDICAID | 200521920 | 05 | IN |   | MEDICAID |