Basic Information
Provider Information | |||||||||
NPI: | 1922051697 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRIHEALTH PHYSICIAN INSTITUTE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GEROS PHYSICIAN EXTENDERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 635257 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452635257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5135695027 | ||||||||
FaxNumber: | 5135695199 | ||||||||
Practice Location | |||||||||
Address1: | 619 OAK ST | ||||||||
Address2: | 4 - WEST | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452061613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5135696780 | ||||||||
FaxNumber: | 5135696738 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 04/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NIENABER | ||||||||
AuthorizedOfficialFirstName: | DONNA | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5138621400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TRIHEALTH PHYSICIAN INSTITUTE | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50001078 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X | NP06244 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 0998783 | 05 | OH |   | MEDICAID |