Basic Information
| Provider Information | |||||||||
| NPI: | 1548297807 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | QUEEN CITY GENERAL & VASCULAR SURGEONS GROUP LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | QUEEN CITY SURGICAL CONSULTANTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1270 SOLUTIONS CENTER | ||||||||
| Address2: | PO BOX 771270 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606771002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135426898 | ||||||||
| FaxNumber: | 5135427972 | ||||||||
| Practice Location | |||||||||
| Address1: | 7502 STATE RD | ||||||||
| Address2: | STE. 1180 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452552800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132328181 | ||||||||
| FaxNumber: | 5136242964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERTEL | ||||||||
| AuthorizedOfficialFirstName: | PEGGY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5132328181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200293310B | 05 | IN | MEDICAID | 2066026 | 05 | OH | MEDICAID | 2066035 | 05 | OH | MEDICAID | 2066044 | 05 | OH | MEDICAID | 200293310E | 05 | IN | MEDICAID | 2065867 | 05 | OH | MEDICAID | 2324336 | 05 | OH | MEDICAID | 200293310A | 05 | IN | MEDICAID | 200293310C | 05 | IN | MEDICAID | 200293310D | 05 | IN | MEDICAID | CD8400 | 01 | OH | RAILROAD MEDICARE | OTHER | 2066053 | 05 | OH | MEDICAID | 2066017 | 05 | OH | MEDICAID |