Basic Information
| Provider Information | |||||||||
| NPI: | 1942255229 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GERIMED, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23128 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452230128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138917574 | ||||||||
| FaxNumber: | 5137931032 | ||||||||
| Practice Location | |||||||||
| Address1: | 4900 COOPER RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452426915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137933362 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | RIVERA | ||||||||
| AuthorizedOfficialFirstName: | EMMANUEL | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5135696780 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65946352 | 05 | KY | MEDICAID | 2719768 | 05 | OH | MEDICAID |