Basic Information
| Provider Information | |||||||||
| NPI: | 1538118104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOSSARD | ||||||||
| FirstName: | TED | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7175 BEECHMONT AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452304111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132327100 | ||||||||
| FaxNumber: | 5132326975 | ||||||||
| Practice Location | |||||||||
| Address1: | 7175 BEECHMONT AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452304111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132327100 | ||||||||
| FaxNumber: | 5132326975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
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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 | 207Q00000X | 35075054 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2188592 | 05 | OH | MEDICAID |