Basic Information
| Provider Information | |||||||||
| NPI: | 1578538955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENNINGS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 MERCY HEALTH BLVD STE 2010 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452111103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139614335 | ||||||||
| FaxNumber: | 5138725769 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 MERCY HEALTH BLVD STE 2010 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452111103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139614335 | ||||||||
| FaxNumber: | 5138725769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 09/26/2019 | ||||||||
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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 | 208600000X | 35085981 | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100056850 | 05 | KY | MEDICAID | 200515190A | 05 | IN | MEDICAID | 64103476 | 05 | KY | MEDICAID | 2580407 | 05 | OH | MEDICAID | P00274332 | 01 | RAILROAD MEDICARE | OTHER |