Basic Information
| Provider Information | |||||||||
| NPI: | 1275639908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MALE REPRODUCTIVE MEDICINE OF SOUTHWEST OHIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2773 ORCHARD RUN RD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454492831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374353110 | ||||||||
| FaxNumber: | 9374356135 | ||||||||
| Practice Location | |||||||||
| Address1: | 5692 FAR HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454292239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374349901 | ||||||||
| FaxNumber: | 9374349107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | JENI | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9374356136 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 35-086518 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.