Basic Information
Provider Information | |||||||||
NPI: | 1720349590 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRIHEALTH G LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GROUP HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4685 FOREST AVE STE C | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452123359 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132467796 | ||||||||
FaxNumber: | 5138528525 | ||||||||
Practice Location | |||||||||
Address1: | 3125 HAMILTON MASON RD | ||||||||
Address2: |   | ||||||||
City: | HAMILTON | ||||||||
State: | OH | ||||||||
PostalCode: | 450115307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132467000 | ||||||||
FaxNumber: | 5138952147 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2012 | ||||||||
LastUpdateDate: | 08/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NIENABER | ||||||||
AuthorizedOfficialFirstName: | DONNA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SR VP & CORPORATE COUNSEL | ||||||||
AuthorizedOfficialTelephone: | 5135696062 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TRIHEALTH G LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X |   | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
ID | Type | State | Issuer | Description | 2565399 | 05 | OH |   | MEDICAID |