Basic Information
Provider Information | |||||||||
NPI: | 1306890181 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSSI | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 636930 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452636930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5139815123 | ||||||||
FaxNumber: | 5139815015 | ||||||||
Practice Location | |||||||||
Address1: | 770 W HIGH ST | ||||||||
Address2: | SUITE 460 | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 458013990 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192264300 | ||||||||
FaxNumber: | 4192264305 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 10/30/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 35-08-3337 | OH | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   |
ID Information
ID | Type | State | Issuer | Description | 1306890181 | 01 |   | NPI | OTHER | 3004898000 | 05 | WV |   | MEDICAID | 310917085134 | 01 | OH | CARESOURCE MEDICAID | OTHER | 2500234 | 01 | OH | MOLINA MEDICAID | OTHER | P00066040 | 01 |   | RR MEDICARE | OTHER | 000000181653 | 01 | OH | UNISON MEDICAID | OTHER | 000000310729 | 01 |   | ANTHEM BCBS | OTHER |