1144546086 NPI number — MARY KATHLEEN BISTER M.D.

Table of content: MARY KATHLEEN BISTER M.D. (NPI 1144546086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144546086 NPI number — MARY KATHLEEN BISTER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BISTER
Provider First Name:
MARY
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144546086
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7120 N BLACKBURN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45701-8782
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-846-4149
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
231 ALBERT SABIN WAY
Provider Second Line Business Practice Location Address:
MSB 1551, M.L. 0769
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-558-8114
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  35.123233 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 114828700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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