Healthcare Provider Details

I. General information

NPI: 1376146118
Provider Name (Legal Business Name): DR. MICHAEL GARRET KERYESKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9525 KENWOOD RD STE 1
BLUE ASH OH
45242-6177
US

IV. Provider business mailing address

161 JACOBS CT
LOVELAND OH
45140-8547
US

V. Phone/Fax

Practice location:
  • Phone: 513-793-7171
  • Fax:
Mailing address:
  • Phone: 724-681-9815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1003693
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: