Basic Information
| Provider Information | |||||||||
| NPI: | 1972617728 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL COMMUNITY HEALTH BOARD OF HAMILTON COUNTY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 532 MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135592000 | ||||||||
| FaxNumber: | 5135592020 | ||||||||
| Practice Location | |||||||||
| Address1: | 532 MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135592000 | ||||||||
| FaxNumber: | 5135592020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 02/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | BENNETT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5135592913 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 080 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | MC21-12 | 05 | OH | MEDICAID |