MEDICARE: QUEEN CITY MED MART 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	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891725263
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEEN CITY MED MART LLC

Provider Business Mailing Address
First Line	:	10780 READING RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45241-2531
Country	:	US
Telephone Number	:	513-733-8100
Fax Number	:	513-733-8449

Provider Business Practice Location Address
First Line	:	10780 READING RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45241-2531
Country	:	US
Telephone Number	:	513-733-8100
Fax Number	:	513-733-8449

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DAVID P FESMAN
Credential	:
Telephone Number	:	513-733-8100

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	12/20/2017

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Directions to “QUEEN CITY MED MART LLC ” Practice Location

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