Basic Information
| Provider Information | |||||||||
| NPI: | 1528062890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENTIS | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4685 FOREST AVE STE C | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452123359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132467800 | ||||||||
| FaxNumber: | 5132467852 | ||||||||
| Practice Location | |||||||||
| Address1: | 8245 NORTHCREEK DR | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452362283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132467000 | ||||||||
| FaxNumber: | 5132465284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 07/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 35039575E | OH | N | Other Service Providers | Specialist | 207K00000X | 35.039575 | OH | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207KA0200X | 35.039575 | OH | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
ID Information
| ID | Type | State | Issuer | Description | 0459329 | 05 | OH | MEDICAID | 0402853 | 05 | OH | MEDICAID |