Basic Information
| Provider Information | |||||||||
| NPI: | 1558460204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELVIN | ||||||||
| FirstName: | C. | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 HARVEY AVE | ||||||||
| Address2: | STE. 104 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135859500 | ||||||||
| FaxNumber: | 5135859505 | ||||||||
| Practice Location | |||||||||
| Address1: | 3131 HARVEY AVE | ||||||||
| Address2: | STE. 104 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135859500 | ||||||||
| FaxNumber: | 5135859505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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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 | 207R00000X | 35-047904 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64784853 | 05 | KY | MEDICAID | 0546832 | 05 | OH | MEDICAID | P00884838 | 01 | OH | MEDICARE RR | OTHER |