Basic Information
| Provider Information | |||||||||
| NPI: | 1629042361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRABENDER | ||||||||
| FirstName: | WAYNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636461 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409881009 | ||||||||
| FaxNumber: | 4409881225 | ||||||||
| Practice Location | |||||||||
| Address1: | 578 N LEAVITT RD | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440011131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409885226 | ||||||||
| FaxNumber: | 4409885645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 12/14/2009 | ||||||||
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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 | 35048403 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0522714 | 05 | OH | MEDICAID | 0236248 | 05 | OH | MEDICAID |