Basic Information
| Provider Information | |||||||||
| NPI: | 1245422161 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEIDI | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 237 WILLIAM HOWARD TAFT RD | ||||||||
| Address2: | 2ND FLOOR, CBO2-3, ATTN: CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132638551 | ||||||||
| FaxNumber: | 5133664480 | ||||||||
| Practice Location | |||||||||
| Address1: | 4805 MONTGOMERY RD | ||||||||
| Address2: | SUITE 154 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452122198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135851713 | ||||||||
| FaxNumber: | 5135851734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2007 | ||||||||
| LastUpdateDate: | 11/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 57008651 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 7100228180 | 05 | KY | MEDICAID | 0075292 | 05 | OH | MEDICAID |