Healthcare Provider Details

I. General information

NPI: 1093371312
Provider Name (Legal Business Name): PAI PARTICIPANT 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MARIETTA RD
CHILLICOTHEE OH
45601-9433
US

IV. Provider business mailing address

PO BOX 639676
CINCINNATI OH
45263-9676
US

V. Phone/Fax

Practice location:
  • Phone: 859-291-4800
  • Fax:
Mailing address:
  • Phone: 859-291-4800
  • Fax: 859-655-8588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL C FORD
Title or Position: AUTHORIZED OFFICAL
Credential:
Phone: 484-643-2629