Basic Information
Provider Information | |||||||||
NPI: | 1891729158 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANNENBERG | ||||||||
FirstName: | ALAN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4030 SMITH RD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452091957 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5134213494 | ||||||||
FaxNumber: | 5133452606 | ||||||||
Practice Location | |||||||||
Address1: | 4030 SMITH RD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452091957 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5134213494 | ||||||||
FaxNumber: | 5133452606 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2006 | ||||||||
LastUpdateDate: | 12/10/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35049257A | OH | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 25980 | KY | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0129X | 35049257A | OH | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 25980 | KY | N |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 49257 | 01 |   | CHOICE CARE/HUMANA | OTHER | 310804060032 | 01 |   | CARESOURCE | OTHER | 0695636 | 05 | OH |   | MEDICAID | 1702166 | 01 |   | UNITED HEALTHCARE | OTHER | 200001270 | 05 | IN |   | MEDICAID | 8330 | 01 |   | KY BCBS | OTHER | 000000211187 | 01 |   | ANTHEM | OTHER |