Basic Information
| Provider Information | |||||||||
| NPI: | 1538148176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MANZO | ||||||||
| OtherFirstName: | SALLY | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2830 VICTORY PKWY STE 120 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452061786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132453052 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11100 SPRINGFIELD PIKE | ||||||||
| Address2: | UNIVERSITY FAMILY PHYSICIANS-MAPL | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452464112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137822448 | ||||||||
| FaxNumber: | 5135842809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 35.058586 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0837205 | 05 | OH | MEDICAID |