Basic Information
| Provider Information | |||||||||
| NPI: | 1932230364 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRIHEALTH G., LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GROUP HEALTH ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4600 WESLEY AVE | ||||||||
| Address2: | STE N | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452122298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138415519 | ||||||||
| FaxNumber: | 5138411580 | ||||||||
| Practice Location | |||||||||
| Address1: | 3248 WESTBOURNE DR | ||||||||
| Address2: | STE 1 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452485107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134511930 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | BLACKLIDGE | ||||||||
| AuthorizedOfficialFirstName: | MELODIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5138415535 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRIHEALTH G LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 2686482 | 05 | OH | MEDICAID |