Basic Information
| Provider Information | |||||||||
| NPI: | 1679773022 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOCINCY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 S LOOP RD | ||||||||
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| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8598177500 | ||||||||
| FaxNumber: | 8598177851 | ||||||||
| Practice Location | |||||||||
| Address1: | 2960 MACK RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137933933 | ||||||||
| FaxNumber: | 5137938299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 10/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | REIS | ||||||||
| AuthorizedOfficialFirstName: | JOANN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8598177070 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0399980002 | 01 | OH | DURABLE MEDICAL EQUIPMENT | OTHER |