1740284603 NPI number — MR. FREDRICK A OLIVER P.T.

Table of content: MR. FREDRICK A OLIVER P.T. (NPI 1740284603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740284603 NPI number — MR. FREDRICK A OLIVER P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLIVER
Provider First Name:
FREDRICK
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

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:
1740284603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4555 LAKE FOREST DR
Provider Second Line Business Mailing Address:
STE 150
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45242-3781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-327-2278
Provider Business Mailing Address Fax Number:
888-322-2278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4555 LAKE FOREST DR
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45242-3781
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-327-2278
Provider Business Practice Location Address Fax Number:
888-322-2278
Provider Enumeration Date:
06/09/2005

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: 2251X0800X , with the licence number:  PT 09980 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251X0800X , with the licence number: 005788 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2630442 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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