Basic Information
| Provider Information | |||||||||
| NPI: | 1386609881 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 237 WILLIAM HOWARD TAFT RD | ||||||||
| Address2: | 2ND FLOOR, CBO 2-3 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137927800 | ||||||||
| FaxNumber: | 5137927807 | ||||||||
| Practice Location | |||||||||
| Address1: | 11140 MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452492309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137927800 | ||||||||
| FaxNumber: | 5137927807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35046812 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 35046812 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 000000238182 | 01 | ANTHEM MIDDLETOWN | OTHER | 64860562 | 05 | KY | MEDICAID | 0549464 | 05 | OH | MEDICAID | 2520401 | 01 | UNITED | OTHER | 0642403 | 01 | AETNA | OTHER | 100335970 | 05 | IN | MEDICAID | 000000019745 | 01 | ANTHEM | OTHER |