MEDICARE: SUBI HEALTHCARE SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	356755	OTHER	OH	STATE LICENSE

General Provider Information

NPI Number	:	1528618444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUBI HEALTHCARE SERVICES LLC

Provider Business Mailing Address
First Line	:	4124 DURHAMS XING
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-1759
Country	:	US
Telephone Number	:	513-601-2359
Fax Number	:	770-573-9513

Provider Business Practice Location Address
First Line	:	4124 DURHAMS XING
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-1759
Country	:	US
Telephone Number	:	513-601-2359
Fax Number	:	770-573-9513

Authorized Official
Title or Position	:	MANAGER
Name	:	STEVEN SMITH
Credential	:
Telephone Number	:	502-244-9859

Provider Enumeration Date	:	09/12/2019
Last Update Date	:	09/12/2019

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