Basic Information
Provider Information | |||||||||
NPI: | 1518938471 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY OF CINCINNATI SURGEONS-TRAUMA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2830 VICTORY PKWY | ||||||||
Address2: | STE. 320 | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452061785 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132453300 | ||||||||
FaxNumber: | 5132453340 | ||||||||
Practice Location | |||||||||
Address1: | 231 ALBERT SABIN WAY | ||||||||
Address2: | ML 0558 | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452670001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132453300 | ||||||||
FaxNumber: | 5132453340 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2006 | ||||||||
LastUpdateDate: | 01/29/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RICHARDS | ||||||||
AuthorizedOfficialFirstName: | J | ||||||||
AuthorizedOfficialMiddleName: | TALIESIN | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, BUSINESS AFFAIRS | ||||||||
AuthorizedOfficialTelephone: | 5132453300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
ID | Type | State | Issuer | Description | 2493798 | 05 | OH |   | MEDICAID |